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Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, March 14, 2018

Unusual Attachment Behaviors and Their Implications

The concept of attachment—a toddler’s wish to stay near a familiar caregiver, especially when frightened, tired, sick, or injured, or when in an unfamiliar place—has given rise to thousands of research studies and much speculation sine it was formulated by John Bowlby in the 1950s. Some of Bowlby’s work focused on the attachment experiences of children who later turned out to be delinquents, so from an early point ideas about attachment have been connected with explanations of undesirable behavior and predictions of emotional problems.

The most established measure of attachment, the Strange Situation Paradigm, uses an artificially slightly scary situation to look at how toddlers respond to their mothers’ leaving them briefly in a strange place, and the way they respond to reunion with her when she returns. The great majority of young children behave in the Strange Situation in ways that let researchers categorize them in one of three categories. The largest number are classified as securely attached, and smaller proportions as either insecure-avoidant or insecure-ambivalent in their attachment relationship to the specific familiar adult who is with them in the test situation. All of these categories are within a normal range of social and emotional development , and although “secure attachment” sounds better than the other categories, it is not necessarily strongly associated with any great developmental advantage. These attachment classifications may change over time and may well be different from other attachment classifications a child would receive if tested with a different familiar person--- that is, the attachment classification is neither permanent or “in the child”, but is changeable and “in the relationship”. 

Because similar language is used, people may jump to the conclusion that insecure attachments lead to so-called “insecure” adult behavior like lack of self-confidence or jealousy or poor social skills, but this is not the case. Insecure attachments are not considered the ideal for toddlers, but neither do they require treatment to prevent current or later difficulties. In addition, it is very clear that the Strange Situation Paradigm was developed for research work comparing groups of children and not for clinical purposes—insecure attachment classifications in individuals are not diagnoses.

Years after Bowlby’s work, the psychologist Mary Main and her colleagues described a form of toddler behavior in the Strange Situation that was different from the three primary classifications of attachment. They referred to this behavior as “disorganized attachment”. Young children who were classed as having disorganized attachment behaved in quite unusual ways when reunited with their mothers after a very brief separation. Some froze in place after starting to approach the mothers; some backed toward the mothers; some simply collapsed to the floor. For their parts, the mothers, many of whom had endured earlier traumatic experiences, often appeared frightened as they looked at the children.  It seemed that the children needed and wanted contact with their mothers, but they had no effective way to get this because of their own state of fearfulness, perhaps associated with the mothers’ apparent fear. Not only was the relationship between child and mother disorganized and inadequate to give the child needed support and comfort, but children in this kind of relationship would not be able to use their mothers as “secure bases” to give them confidence for exploring and learning—one of the most important benefits of toddlers’ attachment.

Disorganized attachment has been thought of for years as an important indication of the need for treatment of mother and child. But recent work suggests that it is not completely clear how disorganized attachment develops, so it is in turn not completely clear what to do about it. In one recent article (Duschensky, R. [2018]. Disorganization, fear, and attachment: Working towards clarification. Infant Mental Health Journal, 39, 17-29) , the author suggests three different pathways by which toddlers may have arrived at disorganized attachment behavior: serious rejection by the mother, traumatic experiences leading to emotional dysregulation, and temperamental characteristics present at birth. These different possibilities would suggest different treatment approaches, so simply screening young children for disorganized attachment does not necessarily give useful guidance about what help to offer. And, once again, the Strange Situation Paradigm was never intended to make clinical decisions about individuals, but was created as a way to compare groups for research purposes.

Research on disorganized attachment has looked at whether this form of toddler behavior toward a mother is associated with abusive treatment. It’s easy to see why this question would be asked, because two of the pathways to disorganized attachment mentioned above – rejection by the mother and traumatic experiences—could be connected with abuse. Indeed, there are weak statistical relationships between child abuse and disorganized attachment. But these correlations unfortunately have led some practitioners to the idea that disorganized attachment behavior can be used to screen families for child abuse. This conclusion is wrong for various reasons. One is the oft-repeated but equally oft-forgotten fact that correlation of two events does not show that one causes the other. It’s possible that abusive treatment of a child could cause that child to show disorganized attachment behavior, but it’s also possible that children who for other reasons show unusual attachment behavior could trigger both fear and abusive treatment in their caregivers. Even more likely, additional factors like poverty and family trauma could cause both disorganized attachment behavior and abusive treatment, or could cause one or the other separately. In any case, disorganized attachment behavior cannot be used as a proxy measure or screen for child abuse; however much time and resources this approach might save, it would not find all cases of child abuse, and it would find many false positives as children who had never been treated abusively could still show disorganized attachment behavior.

A recent article on disorganized attachment, written by a large number of well-known attachment experts, has clearly stated the limits of usefulness of the disorganized attachment classification ( Granqvist, P., et al. [2017]. Disorganized attachment in infancy: A review of the phenomenon and its implications for clinicians and policy-makers. Attachment & Human Development, 19, 534-558 ). The paper commented on four assumptions about disorganized attachment that they characterized as false and misleading. These were first, that attachment measures can be used to evaluate individual children in judicial or child protective contexts; second, that the presence of disorganized attachment behavior reliably shows that a child has been maltreated; third, that disorganized attachment behavior reliably predicts emotional or behavioral problems in the future; and fourth, that disorganized behavior indicates a lasting characteristic of the child rather than one that can be influenced by changed circumstances. The last assumption, particularly, is contradicted by the fact that it is not unusual to see some mild level of disorganized attachment behavior occur in toddlers in the Strange Situation, especially if they come from challenging environments.

If children show organized insecure responses in the Strange Situation, and if their families need treatment or services, a goal may be to increase attachment security, but this does not mean that insecurity is or predicts serious problems. If toddlers show severely disorganized attachment behavior, they and their families may well need help for one or more reasons, and various kinds of help (as well as maturation) may encourage better organization of relationship-related behavior. However, it should never be assumed either that clinical work with individuals can usefully be based solely  on the observation of disorganized attachment, or that disorganized attachment shows that a child has been maltreated and signals the need for authorities to intervene in the family. Removal of the child should not be contemplated simply because of disorganized attachment behavior.

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