Tag Archives: Attachment Theory

Growing the Attachment Strategies of Preschool Children

Important Note: The image in this post and in all the previous ones are not images of the children discussed in the posting. They are simply children whose photos I have collected throughout my travels.

I am going to offer several ways of doing this, with the understanding that I will continue to think about it and add more later.

The first option is to intervene in the school setting with the help of teachers and other school professionals. The second is consultation to the parents, for example, video feedback. The third is dyadic or family psychotherapy. The fourth is individual psychotherapy for the child; this would necessarily include meetings with the parents. These options are offered in order of increasing intensity of intervention with the idea that if parents choose an intervention of lesser intensity that proves ineffective, they may then choose a more intensive alternative.

Intervention in the school setting is predicated on the assumption that school is a safe environment; that means that the child is adequately compliant with the teachers’ directives, follows the school routine, can access the school curriculum, and can relate to peers relatively well. If the school is safe for the child, the teacher and parent can prepare him or her for appropriate behavior at pickup by breaking up the transition into manageable steps, previewing the experience, and having a teacher available to coach the child and parent through the reunion.

The parent should follow up afterwards with behavior designed to consolidate the positive reunion by encouraging the child to talk about her day and giving the child comforting feedback for difficulties and positive recognition for achievements. This is the tricky part, because the pattern that gets established when the child makes a fuss about pickup generates stress in both parent and child, so that warm, responsive communication at pickup time is usually contaminated with anxiety. Even when the pickup is successful, both parent and child are anticipating some negative experience. Also, there is an unconscious pull back into the problem pattern. That is because it is a habit, well practiced and therefore “simpler”, taking less energy in the short run, though more in the long run.

The parent can try to make declarative statements instead of direct questions that put the child on the spot – starting the comment with “I’ll bet” or “I wonder if” or “I’m thinking that”, for example, “I’ll bet that you liked the cooking activity today,” or “I wonder if it was sad for you that Martha was absent from school today.” If the child gives monosyllabic responses, just tell her that you guess she needs to rest after a long day and maybe you can talk about it later.

The thinking behind this plan is not strictly behavioral. It draws on Attachment Theory and nonlinear systems theory (odd bedfellows, actually) in that it seeks to practice more adaptive interpersonal patterns – reunion – over and over again, with the input of support (“energy”) from the teachers. If a new strategy for reunion after a separation is more successful and is practiced enough to become a stable part of the parent-child relational repertoire, it can facilitate the child’s development in a more general sense.

I will discuss the other options in subsequent posts.

The Problem of “The Little Girl with a Curl”

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A particular problem has come to my attention over the years consulting to a preschool – children behaving in controlling and sometimes aggressive ways to parents at school transitions. Teachers report that the child behaves badly with his or her parents at drop off and pick up. Often the teachers express amazement that the children who seems well behaved in school, can change dramatically when they are with their parents – boss them around, even push or hit them. Another behavior characteristic of this problem is the child running away from the parent or refusing to come with them at pick up time. It is difficult for even the most empathic teacher to avoid the suspicion that the parents are somehow allowing their child to mistreat them by not setting adequate limits for the child. Supportive evidence is sometimes found in parents restraining from disciplining their children in the school.

This situation reminds me of a Mother Goose rhyme that my parents read me when I was a young child about a “little girl with a curl”. The rhyme goes, “There was a little girl who had a little curl, right in the middle of her forehead. When she was good, she was very, very good. But when she was bad, she was horrid.” I always secretly worried that I might be that girl.

Perhaps partly for that reason, I have given this problem a good deal of thought. My conclusion is that the answer to the mystery of the “little girl with a curl” mystery is rather complicated. The reason I say this is that when I talk to the parents of these children, I get a wide variety of answers about their child’s behavior in different settings. Some children are relatively well behaved in most settings and become suddenly noncompliant and belligerent at pick up time. Other children are compliant when they are involved in activities but become disorganized and unhappy during unstructured time at home and in school. Some children are usually cooperative but have difficulty with all significant transitions – bedtime, getting up time, leaving an activity, etc. Other children are always a handful.

What ties together all the children who fuss at pick up time and behave defiantly with their parents but not necessarily with their teachers? All these children are expressing difficulty with finding a positive strategy for reuniting with their parent. The subject of reunion strategies falls into the domain of a theory that informs much current developmental research and that has now also become popular in the vernacular – Attachment Theory. I have talked about Attachment Theory in other blog postings, because of its importance in research. The essential feature of Attachment Theory is that it presents the infant’s essential motivation as staying close to the parent in order to feel safe and secure. If the infant achieves the capacity to feel secure in his relationship to his mother, then he is free to explore the world, knowing that he can easily return to the safety of that connection.

We know that an important but primitive response to threat is running away or aggression. Remember that the “fight or flight” response of the sympathetic nervous system is one of the main “bottom up” as opposed to “top down” responses of the stress regulation system. That means that we must feel confident in our capacity to achieve security in order to use our thinking brain to tell us what we should do in a threatening situation. Transitions are inherently threatening, even small ones, because they require us to disorganize ourselves on the way to a new organization. That is, we have to stop playing in the sandbox in order to join Mother, get into the car, stay still in the car seat, etc. Playing in the sandbox is a complex organization involving a cognitive plan (building a castle), a motor rhythm (dig, pour, pat; dig, pour, pat), an affective and physiological state (contented, calm); and maybe even a compelling interpersonal experience (collaboration or competition with a peer). That is a lot to take apart in order to get into the car. And the hardest part is the disorganization in between the sandbox play and the car seat, between one organized state and the other. How do children manage that transition? It starts in infancy with the regulatory aid of the parent.

These interpersonal regulatory patterns that start in infancy gain power and stability as parent and child repeat them over and over again during the course of daily life. One pattern, that Attachment Theory would call “secure”, is demonstrated by the parent-child dyad who are able to support the child in managing all these disorganizing (and therefore threatening) experiences of – letting go his plan of building the castle, discontinuing the motor rhythm, interrupting the calm and contentment, and giving up the competition or collaboration – and maintaining adequate regulation and sense of security until the new car seat organization is established. I say “parent-child dyad” because I do not see this activity of facilitation transition as emanating exclusively from the parent. Although sophisticated advocates of Attachment Theory would probably agree with me, Attachment Theory largely tends to place the responsibility squarely on the mother, who carries attachment patterns within her even before her child is born, according to the AAI.

I will tell you how I use these thoughts about Attachment Theory in my search for answers to the “girl with a curl” problem in my next posting.

Why is Temperament Important to Parents and Teachers?

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Roughly 10-20% Caucasian children are shy and hesitant in unfamiliar situations. Another 10-20% are sociable and intrepid in response to novelty. The underlying features of these predispositions usually referred to as “temperament”, remain remarkably consistent over time. It has also been found that the caregiving environment in the early years can significantly influence the behaviors characteristic of these temperaments. That makes the study of temperament particularly relevant to this blog.

Nancy Snidman, a colleague of the pioneer researcher in temperament, defines temperament as a “predisposition to respond to the environment in certain ways” (lecture to UMB IPMHPCP, March 6, 2016). The baby comes into the world with certain temperamental qualities. These temperamental qualities may be due to genetics or epigenetics – influences from the environment in the womb. Children’s temperament influences the way they react to their environment – physical, social, and emotional. For example, a child’s temperament affects the way they react to novelty, sensory stimulation, or transitions. How does temperament at infancy translate to temperamental characteristics such as shyness in a preschool child? What does the “shy” infant look like as an older child or adult? Snidman and Kagan did a series of longitudinal studies to try to answer these questions.

Kagan and Snidman studied 400, 4-month old babies and classified them as high reactive (HR) and low reactive (LR) on the basis of their response to auditory, visual, and olfactory stimuli. They observed the babies’ responses in the form of heart rate increase, motor arousal (such as limb flexion and extension, motor tension, and back arch) and fretting or crying. They looked for the extremes of HR and LR babies and started to follow them.

They postulated that the HR children had inherited a low threshold of excitability in the amygdala; a part of the mid-brain called the limbic system, and the related limbic areas. The amygdala sends signals to the autonomic nervous system, communicating a sense of threat in the environment.

They studied the babies’ physiology and behavior in response to a number of laboratory procedures, from 9 months to 15 years. Some of these procedures were mild, such as puppets or tasting sweet and sour liquids, and some were more challenging, such as a toy robot and a stranger approaching wearing a lab coat and a gas mask. The two extreme styles of temperament, HR or LR, or behaviorally inhibited (BI) – shy, wary of novelty, slow to approach, or behaviorally uninhibited (BU) – sociable, comfortable with novelty, were remarkably consistent over the years.

Interestingly, the researchers found that as the kids got older the physiological markers were more important than the behavioral ones. This was because the children were taught to be polite. It was less the general behavior to strangers that distinguished the HR from the LR kids, and more the smiles and spontaneous comments. When children are presented with the same stimuli in repeated exposures, for example when they are shown invalid pictures (a horse head on a fish body), they usually habituate to the stimulus. That means their reaction becomes smaller with repeated exposures. In the case of HR kids, however, there is no habituation! That means that although they look more and more like their LR peers in terms of social behavior, their heart rate, pupillary dilatation, muscle tension, and stress hormones remain more reactive.

This is very interesting to me in my work with children and families. For more than two decades, Attachment Theory has dominated research in child psychology. This way of understanding child development minimizes the contribution of temperament. Yet, I have found temperament a very useful way of making sense of some of the problems that parents bring to me regarding their children’s behavior. It is also helpful to me when I consult to preschool teachers. In the next blog posting I will describe how I use ideas of temperament to help parents and teachers understand the children in their care.

Readings

Schwartz C, Snidman N, Kagan J (1999). Adolescent social anxiety as an outcome of inhibited temperament in childhood, JAACAP 38(8):1008-1015.

Kagan J (1997) Temperament and the reactions to unfamiliarity, Child Development 68(1):139-143.

Kagan J (1989). Temperamental contributions to social behavior, American Psychologist 44(4):668-674.

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“Ghosts in the Nursery”

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For this mothers’ group meeting the mothers chose the topic of the relationship with their own mothers. This is a very important subject and one that has been central to thinking in psychology for about half a century now. I will organize my thoughts about it into three categories. The first is psychoanalytic or psychodynamic thinking about the subject. The second is Attachment Theory, and the third is the developmental perspective introduced by Tronick in his Mutual Regulation Model (Tronick, 2007).

First of all, Sigmund Freud didn’t pay much attention to the mother’s relationship to her own mother in his theorizing. In fact, he didn’t blame the mother much at all. In his famous case of a child with a horse phobia, “Little Hans” – although there was plenty of evidence of Little Hans’ mother’s emotional difficulties and of his parents’ marital conflict at the time (this was revealed rather recently when the Sigmund Freud Archives revealed information gained from interviews of the father and of Little Hans himself as an adult) – Freud attributed most of Little Hans’ problems to Hans’ own inner conflicts generated by his developmental stage and position in the family – his “Oedipal Conflict” (Freud, 1909), (Chused, 2007).

The early child analysts who studied with Sigmund Freud’s daughter, Anna Freud, gave more thought to the influence of parenting. Anna Freud and Dorothy Burlingham created “Hampstead War Nurseries” in which the impact of children’s separation from their mothers was observed and the recommendation was made to keep children with their families whenever possible, even during the bombings (Midgely, 2007). One of the circle of early child analysts around Anna Freud, Berta Bornstein, wrote a classical paper describing her analytic treatment of the little boy she called “Frankie” (Bornstein, 1949). In this paper she hypothesized that Frankie’s mother’s relationship with her own mother – and to her preferred older brother – affected her own difficulty bonding to newborn Frankie and influenced her continuing relationship with her son.

Another follower of Anna Freud was Selma Fraiberg, who became famous for her book about early child development called “The Magic Years”. Fraiberg made an important contribution in our understanding of early development through clinical her work with the mother-child relationship. She wrote a classic paper called “Ghosts in the Nursery” about the influence of a woman’s experience with her mother on her relationship with her own child (Fraiberg, Adelson, & Shapiro, 1975). In this paper, Fraiberg states, “In every nursery there are ghosts. They are visitors from the unremembered past of the parents; the uninvited guests at the christening” (p. 387). One of Fraiberg’s followers, Alicia Lieberman, has written about a counteracting influence that she calls, “The Angels in the Nursery” (Lieberman et al, 2005). Continue reading →

A Safe Place

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Before I begin this posting, I would like to say a word about confidentiality. In my postings about children in the U.S., I avoid writing about specific children, preferring to create a composite of a number of children I have known that will best illustrate the point I am making. When I write about children in other countries I do the same. I have begun to visit a number of orphanages in El Salvador, and in order to protect the confidentiality of the children in these homes, I will avoid referring to specific homes and also disguise the children in other ways.

This posting is about my recent trip to El Salvador.

By the time I reach the gate of my flight to El Salvador – in Houston or Miami – I begin to feel that I am almost there. Spanish is the language most spoken at the gate. The passengers include many people of modest means preparing to return home or to visit relatives. Sometimes I imagine there is an appreciative attitude of the passengers on the plane, as if they feel lucky to be there, rather than hassled by yet another plane trip. After arrival at the San Salvador Airport, and after passing through immigration, the tropical air surrounds me with warmth and moisture, tropical birds squawk in the trees outside the airport, and I have the full sensory experience of really being there. A large crowd is always waiting to greet relatives. There is more emotional energy in the crowd – more intensity – than in the relatively restrained crowds waiting in U.S. and Western European airports.

This time taking my hotel’s shuttle into the city, I relax and enjoy the familiar images of the drive. Pick-up trucks with dozens of people sitting in the back or standing and hanging onto the sides, buses that light up at night when they stop to discharge or pick up passengers, illuminating a multitude of people wearing bright colors, traffic diversions with orange cones directing you in circuitous routes for no reason I can determine (sometimes they are for the police to check your papers but sometimes there is no one there at all). This time I arrived at night and the dark hills were spotted with the lights of civilization.

Whenever I come here, I have an idea that I want to communicate to the caregivers and a plan of how I want to do that. Every time I come, during the course of my visit I completely fracture my original plan and end up with something else. It is an exciting experience.

This time I came with the plan of helping both the staff and the children to tell their life stories. The idea was inspired by a young colleague of mine, Molly, who was going to spend some time at one of the homes and was interested in the theme of life stories and how they are related to learning and the desire to learn. I also had in mind the AAI and the research correlating the “coherence” of the narrative of adults about their early caregiving experiences to the security of their attachment style in adult life and to their behavior as parents (Main, 2000). Since the kind of psychotherapy available in Boston is not possible for the children in the children’s homes of El Salvador, and since I am not sure that it would make sense for them anyway (Perry, 2008) I wondered if helping them tell their stories might be a possible therapeutic alternative.

In all of the homes I visited, my young colleague and I gathered the caregiving staff and asked the caregivers to tell stories about their lives. We did this because we hypothesized that through telling their own stories they could learn the value of telling stories. That might result in their encouraging the children to do the same. We asked them to begin with an event that occurred to them at the age of one of the children in their care. The stories they told included several memories of being bullied or teased, or even beaten, and how that experience served to help them empathize with the children they cared for. They also reported memories of being left alone in childhood or expected to take on excessive responsibility. Many told stories of struggling in school. One story was about a teacher being the only one to notice her sadness, during the time her parents were getting divorced.

We then asked the caregivers to tell a story about their parents. That question elicited stories of abandonment – temporarily or permanently, literally or emotionally – by their mothers. Father figures were either absent or deeply flawed – either harsh and punitive or alcoholic. Many caregivers were brought up by their grandmothers, and their grandmothers were generally described as kind and loving. Some of them told stories about their family members – mothers, fathers, older siblings – leaving them to find jobs in the U.S. I was reminded of the families I see sometimes at the Cambridge Hospital who have emigrated from El Salvador, leaving family behind. They represent the counterpoint of the caregivers in our groups. Some of the families in Cambridge willingly take in the children of debilitated relatives in El Salvador. Others avoid them, attempting to escape the guilt of having left behind the poverty and despair of their home country. The escape, though, is only partial, because their children – whom they are bringing to the child psychiatry clinic – always carry some of the burden of their parents’ painful past.

So, we – Molly and I – were trying to find a way of helping the children tell their stories. The trouble was that every way we thought of seemed artificial and we knew would fall flat. Then in the home I have been visiting the longest, a child asked me if I had videos of him when he was little. I promised to look for them, and the next day I brought the videos I had found to the home. The children were mesmerized by the videos of my first visit to this home, in 2004. Laughing, they called out the names of people they recognized in the film. Occasionally, they would ask about people whom they did not recognize, or they would misidentify a person who had left as someone who was still present. I wondered if the fact of their departure posed a threat that needed to be denied.

Sometimes I would stop the video and ask the children what they thought the child on the video was thinking and feeling. They had a hard time doing that. In one video, a little boy dropped something on the floor and then became preoccupied with his “misdeed”, looking down and up with big expressive eyes, in a sweetly comical manner. The children laughed and responded that he was clowning. They could not recognize that he was anxious and ashamed about having “broken a rule”. In another film a child was refusing to eat when being fed by the caregivers and later clearly demonstrated her intention of feeding herself. The children were able to identify her oppositionalism but not her expression of agency. I thought that showing them videos such as these and pausing the video at moments when emotion was expressed – as I did – could be an excellent tool to help them grow a “theory of mind”. Rather than the more artificial scenarios Molly and I had discarded as potentially stressful to the children, this was spontaneous and initiated by the children themselves.

The single woman director of one of the homes noted ruefully that since the children had gotten older, she had not been able to maintain the same routines that had been so organizing and comforting to them when they were younger. For example, she had previously begun each meal with group prayers led by one child at a time. The patterned rhythmic movement included in the clapping and singing of the prayers – I had always thought – contributed to the children’s ability to sit together at mealtime and talk to each other. This routine, and similar ones, seemed to help in regulating the children and making them feel secure. Now that the children in the home included a group of teenagers, meals were more chaotic and unpleasant, with less conversation and positive engagement among the children and caregivers. Struggling to maintain order and discipline in general, and feeling burdened by having to assume the role of disciplinarian, the director was loath to engage in yet another struggle. Yet mealtimes had been an opportunity to pull the “family”, together in the past, and a chance to reconnect with the spiritual core of the community, in the blessing. There was a powerful meaning to that ritual.

Coincident with my visit to the homes was the arrival of “The Navy”, an exciting event in which the US Navy stationed in the city sent a group of young navy men to do activities with the children. The children loved these experiences and adored the kind, strong, young men who came to play games with them. As I talked to the director in anticipation of the visit of “The Navy”, it occurred to me that the military was expert at discipline and team building. Maybe they could help. The next day when the officer, a personable and clearly intelligent young man in charge of the Navy team, introduced himself to me, I told him about my idea. Would he consider designing an exercise for the children to do at the beginning of the meal to help them organize “body and soul” for the day? He said he thought they could do that. When I expressed regret that I would not be able to see the product of their efforts, he promised to make a video and send it to me. In the absence of the regulating ritual of prayer at the beginning of meals, I had been been searching for another predictable ritual that could introduce movement and rhythm into the lives of the children. I knew that such a ritual could enhance their regulatory capacity. Maybe this was an answer. My hope was that, in addition to mealtime, the Navy could generalize the routine to homework time. But, one step at a time.

In my next posting, I will continue the story of this visit.

Main M (2000). The organized categories of infant, child, and adult attachment: Flexible vs. inflexible attention under attachment related stress. Journal of the American Psychoanalytic Association, 48(4):1055-1097.

Perry B, Szalavitz M (2008). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist’s Notebook, Basic Books.

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March IPMH Meeting: Attachment Theory: Two Views

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In this posting I will summarize the presentations of Marjorie Beeghly and Ed Tronick on the subject of Attachment Theory (AT). Marjorie’s presentation explained and offered video demonstrations of the strange situation paradigm, and Ed’s presentation challenged some of the tenets of the theory. This is a long post, and I apologize, but I wanted to complete the description of the IPMH weekend.

Marjorie Beeghly:

Although we don’t know much about how attachment mechanisms get transmitted from one generation to the next, attachment research is a burgeoning field. The research has generated lots of controversy – sort of like religion or politics. The main idea underlying Attachment Theory is that if the baby learns to trust the mother to comfort him when he is in trouble, he begins to learn that he can trust other people later in life.

It used to be that the mother-child relationship was not thought of very much. Harry Harlow, in the late ‘50’s and early ‘60’s, designed a study with a monkey fed on a wire mother. In spite of the fact that the nourishment derived from the wire mother, the baby spent most of his time on the cloth mother. The tactile comfort of the cloth mother dominated.

WWII – war orphanages. Renee Spitz. The description of infants deprived of their mother for 5 months is haunting. It sounds like Autistic Spectrum Disorder except for the motor retardation. It also look like pictures of children from Romanian orphanages – face vacuous, stereotypic finger movements, etc.

Attachment is bio-behavioral, wired in. when you separate infants from the caregiver, especially in the second half of second year of life – the baby responds with anger, and then sadness. Attachment is only activated under conditions of uncertainty, threat, danger, fatigue, or illness. There are other competing biobehavioral systems, such as exploration and affiliation.

Bowlby’s 4 attachment phases

1. Pre-attachment (birth) – mother’s sensitivity; people are drawn to want to take care of babies .

2. Attachment in the making – 2-6 mo. Lot of brain development, infants start having differential behaviors (crying) to different caregivers, social smile, etc.

3. Clear cut attachment – 6-12 mo. Separation anxiety, motility.

4. Goal corrected part (reciprocal relation) 2 plus years. Bob Marvin researched this stage. Internal working models, felt security gets internalized. Erikson also talked about this idea.

Mary Ainsworth did not design the Strange Situation to measure attachment but instead to study how the three biobehavioral systems interchanged (attachment, affiliation, exploration). She did research in Uganda, and her Uganda findings confirmed in the Strange Situation. It is true that the n of her studies were very small.

Often, adherents of Attachment Theory are critical of Freudian theory. Although S Freud’s theory of infancy did have a “virtual infant” in that it derived from reconstructions of the childhoods of his adult patients, Freud was also an acute observer of children – such as his grandson who threw a spool out of his crib and pulled it back and then repeated it, saying “Fort. Da.” (Gone. There.) – when his mother had left the room, thinking that the infant was representing and attempting to master the separation (Freud, S, Beyond the pleasure principle, The Standard Edition,1920). Also his coaching of the analysis of 5-yo Little Hans (Analysis of the phobia of a five year old boy, The Standard Edition) in 1909 demonstrated sensitivity to children in that he told the father to follow Little Hans’ lead in the conversation (it wasn’t really play), he emphasized tolerance and affirmation in father’s responses, and he was keenly aware of the body-centered focus of children’s inner representational life. Also, Anna Freud with her friend Dorothy Burlingham observed in the war nurseries and were marvelous observers. In one paper that is not well known today they describe the powerful bonds developed by children kept in the same children’s home that lasted years later after they had been separated and adopted (Alpert, A (1945). Infants without families: By Anna Freud and Dorothy T. Burlingham, The Psychoanalytic Quarterly, 14:236-238).

Mary Main described “Disorganized Attachment” (Hesse, E, & Main, M (2000) J Amer Psychoanal Assoc, 48:1097-1127). This is a heterogeneous category, characterized by the lack of a coherent strategy to help the child cope with the stress of separation. It is hypothesized that in this case the source of a secure base is also the source of fear. This attachment category is associated with trauma in mother’s history and also with maternal psychopathology.

In Attachment Theory, you have to have special training to score kids.

In videos of the strange situation, the key is that the child is comforted by the mother after the separation and then able to “explore”, reengage with the toys in the mother’s presence. In avoidant behavior, when the mother returns, the child avoids her, a snub. Some babies ignore the mother. The last clip, from a study of cocaine exposure, was hard to score. The child can’t maintain the calming, plus there is a weird resistant behavior. In high risk populations, the relationship between attachment status and outcome is not so clear; there are so many other factors at play.

Is maternal sensitivity the best or the sole predictor of adjustment in life? DeWolfe and van Ijzendoorn conducted a meta-analysis of 65 studies. Their results confirm that maternal sensitivity is the best predictor but the effect size is small. Temperament: Jerry Kagan.and Nathan Fox, etc. suggest that attachment style is predicted by temperament. Most studies indicate that temperament affects attachment behavior but does not predict attachment status. Temperament can alter the type of subcategory.

Grazyna Kochanska studies MRO (mutually responsive orientation), a dyadic factor. She looked at fearfulness and looked at whether MRO predicted attachment status. Kochanska found that secure children showed less fear at 33 mos and were more joyful. Ambivalent kids were the most fearful and least joyful. Avoidant kids showed increasing negative emotions (counter to temperament). The kids who were angriest later were the kids who were classified as D at one year.

Ed Tronick:

Instead of using AT to characterize infant-caregiver relationships, Ed proposes the following ideas, following a non-linear systems meta-theory (Tronick, E. (2007) The Neurobehavioral and Social-Emotional Development of Infants and Children, New York and London: WW Norton Press):

(1. Infant and adult are active. (2. Infant and adult are intentional. (3. Process of reparation is messy. (4. Form of reparation is unpredictable. (5. Process is co-creative. (6. Specific fittedness – must fit to intentions of infant and adult.

Dynamic systems include engagement with others and with oneself. DST (dynamic systems theory) includes an experiential component for us as humans (Tronick, 2009). When you are successfully gaining information you have an experience of pleasure, expansion, and you seek connection. It is in the co-creation of meaning that this happens. You are flexible and dyadic. When you fail, you have anxiety, withdraw, and are unhappy. Meaning making is a fundamental way of regulating ourselves. It can be in words and also in the body. When it goes wrong, things get disorganized and move towards entropy. To preserve ourselves, we become rigid, defensive, aggressive and hostile, use projection, etc. Kids who are compulsively one way or another are staving off disorganization. They are holding on for dear life (the Spitz kids) and staving off disorganization. Kids with behavior problems are also rigidly organized – they go from one state to another and the pattern in which they go from here to there is unvarying. Bullying, for example, is a rigid pattern; kids who bully gain coherence and a defense against anxiety. Homeostasis – there is a dynamic homeostasis over time, but real homeostatic systems are rigid and not dynamic systems. There are some states that must stay pretty much the same, but we bring to bear a lot of other systems to keep them stable, such as body temperature.

Normal development involves change. Normal disorganization is regulated by the parent-infant system. The infant goes from crawling to walking and disorganizes the crawling system to the walking system; this involves anxiety and takes energy. Change is costly and this is true in part because it is unpredictable, and because you are taking apart the old organization, which is anxiety provoking. The clinician’s work is to maintain the organization while the patient allows for the disorganization of the previous organization and takes the risk of trying something new.

The Jim Coan did a study with the MRI and holding hands. Being alone per se is stressful. You could take Coan’s study as a model of the need to be in the presence of another. In this study, the MRI demonstrated that pain can be mediated by holding the hand of a person with whom the subject was in a relationship better than by holding the hand of a stranger (Coan, J. A., Schaefer, H. S. & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological Science, 17, 1032-1039). ?

Getting attached has to do with forming a relationship and creating a new way of being together, a feeling of “connection”. Bowlby focused on a process going on over time that was related to emotions and making a connection in relationships. We have since somewhat lost focus on the process of Bowlby’s theory, through our attention to the categories. The process of meaning making leads to a different take on attachment relationships. When new meanings are co created they generate a variety of emotions and qualities. This may sound like attachment but we confuse ourselves with this overly broad use of the term. Attachments are primarily about safety, feelings of security and the reduction of fear. We have gone on from these ideas to what may be an unrealistic expansion of the theory. In fact, relationships involve lots of ways of being together. Attachment security and the myriad qualities of relationships can be dissociated. Moreover, relationships contain contradictory emotions. For example, intimate relationships may or may not be secure. An abused child may love the abuser but may not feel secure with him. You don’t only have positive feelings towards someone. In fact, to the extent that you have positive feelings about someone, you also have negative feelings such as the fear of loss of that person. What therapists sometimes have to do is to provide the hope or scaffolding to allow for change. For an individual to hold in mind these contradictory possibilities – love and hate – in the service of something you do not know will happen for sure, threatens organization. To the extent you can simplify it, you resolve many issues, so you protect yourself from having to hold it all at the same time.

A problem with Attachment Theory is that it is often used reductively. For example, just because someone is depressed does not mean that they are disorganized. There are also probably borderline personalities that have secure attachments. Which information would be more valuable to have – an assessment that this child has an insecure attachment or the information that from the time he was 5-yo he was in 9 different foster homes? We have elevated Attachment status to a level that carries too much meaning. People will give a patient a disorganized Attachment status and then go on to mention all the other traumatic features of their lives. In AT models, the Attachment status and clinical diagnosis can be reversed, such that instead of beginning with insecure attachment that leads to depression, you could start with depression and end up with an assessment of insecure attachment. These are all correlation studies. When predictions are made, it suggests causality, but in this case the issue of causality is not at all clear. Take for example, the development of the capacity to reach for an object. All infants at about 15 mos of age, end up reaching for an object, yet every infant gets there through a unique process. We have some understanding of what goes into that process – including gravity – but you can’t predict the particular path an individual child will take to get there (Thelan and Smith, 2001)). You you can predict the outcome but not how the process by which the outcome is reached.

A more variegated process is needed to account for the varieties of normal and abnormal, and Ed proposes the process is meaning making. Meanings come in infinite and multi-leveled forms, all of which are aimed at increasing complexity or coherence (according to the meta-theory of dynamic systems theory). When successful, relationships can take on infinite forms and qualities, intensities and rhythms, and ways of being together in emotional, sexual, and body domains because each of these domains is a domain of meaning making.

Most of the research in AT fails to test alternative hypotheses accounting for long-term stability. Take for example the AAI (Mary Main’s Adult Attachment Inventory). Suppose we consider the AAI to measures of self esteem, ego function, and sense of self. Self- esteem is a mid-level concept. You could think of self actualization, or of Erikson’s theories of development. If we compared Erikson’s theory of development and the AAI, which helps most? The basis for the legitimacy of the AAI is that it indicates the type of attachment but in fact it covers a whole lot of other things that are not discussed. Whereas the AAI proposes to reflect the coherence of thought in relation to the security of attachment, in fact it also reflects coherence of thought in other domains such as self-esteem. There have not been studies about this. Why is it not equally legitimate to state that if you have good self esteem, you are more securely attached? The AAI is really talking about a coherent narrative. Mary Main studied with Liz Bates, a linguist; she originally studied psycholinguistics. So the idea of coherent narrative came to her from this route. What if that one thing we call security picks up on many different things, but security is the only thing we are addressing? For example, when Marjorie talked about the child who had secure attachment, she pointed out shared attention and a lot of things and related them to secure attachment, but these behaviors were not in the coding scheme. It is similar to CBT studies in that if you do studies in CBT you study the manual but you do not study all the other things that are going on such as in the relationship. We do not have process research, but only outcome research. CBT may make you better, but we don’t know what it is about CBT that makes you better. When we take AT our of the laboratory and into the consulting room, we use the term AT as if it had the imprimatur of science, when actually we are only going from our observations about the relationship. We invoke a biologic scientific idea to explain what you should do in the clinical situation. It would be similar to using the strange situation paradigm to help guardian ad lidems make decisions about the child’s custody.

AT also forgets about what predictability means. Bowlby talked about process, but we have reified the status. We forget everything going on between one year and five years of age. If you are in a fairly stable environment, it is likely you will be in the same environment five years from then. What if you get an epigenetic change and it dissipates but then the environment comes in and says, let’s put that gum on the light switch again?

There is also the issue of problematic anchors – the end of the scale for sensitivity is not trauma and neglect. If you use scales, people often avoid using the first and last point. When Ed was taught scaling, he was taught to put down an anchor and scale from there. When people talk about attachment, there is a subtle movement from normal caregiving to neglect and abuse, and the neglect and abuse becomes the convincing anchor. It is the child with neglect and abuse that turns out to have problems at 5-yo. Ed bets that if you took a child with abuse and neglect, the abuse and neglect would be a better predictor of problems at 5, than attachment status. In other words, the “insensitive” parent is more likely to abuse or neglect. The sensitivity scale is problematic – sensitivity is a problematic way of talking about it. Also in most contexts if you are good enough to take care of a child’s fear, chances are that you take care of other things they need as well. We have taken one concept and cast a big net with it and end up with a score. Ed studied the Gusii tribe, who do not play with their infants and habitually do not respond empathically to the infant’s expression of emotion, and he guesses that there are lots of secure Gusii infants. The Gusii are sensitive about regulation but not about emotions.

With AT the marker is that the child is willing to stay with a person who can regulate them and make them feel comfortable, but not everyone has this opportunity. You first have to feel secure and physiologically stable in order to do anything. Lou Sander called these things pre-emptive. Although AT does describe illness or other biological sources of distress such as hunger as factors that may interfere with the development of secure attachment, the importance of these factors is frequently overlooked in the AT literature. One can be reduced to fighting and fleeing. Steve Porges said you first have to make the child feel secure, safe, physiologically well regulated. You can do that and you can stop, or having done that you can do a whole bunch of things – socialization, language, motor skills, etc. If you have been ill, all your resources are going into being not fearful, and you don’ want to be social.

Thelen E, Schoener G, Scheier C, Smith L (2001). the dynamics of embodiment: A field theory of infant perseverative reaching, Behavioral and Brain Sciences 24(1):1-34.

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Need for Creative Solutions

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Since my last posting, I was guided by a colleague to The Better Care Network, and to The Better Care Network Working Paper (Williamson and Greenberg, 2010). This paper describes the deleterious effects of institutional care on children, referencing important studies of institutionalized children, particularly in Rumania, Russia, and African countries. Although it includes a section addressing the Latin American countries, the section is short and reflects the relative lack of literature on residential care of children in this part of the world. The paper attempts to address the general problem of abandoned or neglected children throughout the world. It is a valuable document, but does not attempt to deal with the many specific and unique situations included in this important issue. As the authors acknowledge, “… in some countries and in some specific cases, it (residential care) may be acceptable” (pp. 3-4). The paper offers an example of adolescents living on the street and unable to return to their families of origin, who may use a substitute family or even residential care as “the best currently available alternative to an abusive family situation”, “a short-term measure until the child can be placed with a family” (pp. 3-4).

What the authors do not consider in the paper is the powerful effect of “breaking the cycle” that can occur when young children are removed from depriving and abusive environments and placed in a nurturing and protective “home”. This is what the directors of the children’s homes refer to when they call themselves “cycle breakers”. It is important to note that living in a children’s home does not mean that children must lose the connection with their biological families. It simply means that there are many potential creative solutions to the problem of families who cannot care for their children, and a residential home – at least during the week – may be one of them.

The use of Attachment Theory to support the position against residential care often involves an internal contradiction in that abusive and neglectful “attachment figures” have been shown to be at the root of “attachment disorders” (Lyons-Ruth K, “Attachment disorganization: Unresolved loss, relational violence, and lapses in behavioral and attentional strategies”. In J. Cassidy & P. Shaver, Eds., Handbook of Attachment Theory and Research, NY: Guilford Press, 1998). While true that “it is poverty that pushes most children into institutions”, the fact that poverty is often the result of war and other traumatic events cannot be overlooked. Addressing the roots of poverty often takes generations; children returned to traumatized communities cannot wait for the healing to take place. The “targeted, community-based alternatives to children in need” recommended to replace institutional care are an excellent goal but too often remain a fantasy in the minds of planners or politicians (p. 11).

This well-intentioned and intelligent working paper should not be used to justify the hasty and often ill-advised process of “reunification” of children with families that are not prepared to care for them. Children are growing fast; in many cases they cannot wait for community supports to be put in place.