Medicine:Attachment-based therapy (children)

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Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers.[1] Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy.[2] The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder.

Individual therapeutic approaches

Child–parent psychotherapy (CPP)

Child–Parent Psychotherapy (CPP) is an intervention designed to treat the relationship between children ages 0–5 and their caregivers after exposure to trauma or in high risk situations.[3] This intervention was developed in part from infant-parent psychotherapy, a psychoanalytic approach to treating disturbed infant-parent relationships based on the theory that disturbances are manifestations of unresolved conflicts in the parent’s past relationships. This broader idea is represented as “ghosts in the nursery”, indicating the continued presence of earlier caregiving generations [4] Infant–parent psychotherapy was expanded by Alicia Lieberman and colleagues into child–parent psychotherapy, a manualized intervention for impoverished and traumatized families with children under the age of 5. In addition to the focus on the parents early relationships the intervention also addresses current life stresses and cultural values. CPP incorporates attachment theory by considering how attachment bonds are formed between child and caregiver. CPP considers how traumatic experiences may influence attachment bonds and how caregiver’s sensitivity may influence the infant’s behaviors.;[5][6]) CPP also incorporates developmental theories by considering the influences of risk factors and treatment on biological, psychological, social, and cultural development of both the child and caregiver.[7]

The "patient" is the infant–caregiver relationship. The main goal of CPP treatment is to support the parent-child relationship in order to strengthen cognitive, social, behavioral, and psychological functioning.[8] CPP is delivered in one 1-1.5-hour session per week for a year, with both the child and the caregiver/s.[8] In treatment, the child and caregiver are introduced to the formulation triangle. The triangle helps the child and caregiver to visualize how experiences influence behaviors and feelings and how CPP treatment will target those behaviors and feelings to in turn change experiences.[3] CPP treatment encourages joint play, physical contact, and communication between the child and caregiver.[3] The therapist serves to guide treatment, interpret thoughts and behaviors, and emotionally support the child and caregiver.[3]

CPP is supported by five randomized trials showing efficacy in increasing attachment security, maternal empathy and goal-corrected partnerships. The trials also showed a reduction in avoidance, resistance and anger.[3] The trials were conducted with low income groups, maltreating families, families with depressed mothers and families where children were exposed to domestic violence.[9]

Training for CPP is conducted through the Early Trauma Treatment Network, a division of the Substance Abuse and Mental Health Services Administration’s National Child Traumatic Stress Network (NCTSN).[3] CPP training lasts 18 months.[3]

'Circle of Security'

This is a parent education and psychotherapy intervention developed by Glen Cooper, Kent Hoffman, Robert Marvin, and Bert Powell designed to shift problematic or 'at risk' patterns of attachment – caregiving interactions to a more appropriate developmental pathway. It is stated that it is explicitly based on contemporary attachment and congruent developmental theories. Its core constructs are Ainsworth’s ideas of a Secure Base and a Haven of Safety (Ainsworth et al. 1978). The aim of the protocol is to present these ideas to the parents in a user-friendly, common-sense fashion that they can understand both cognitively and emotionally. This is done with a graphic representation of a circle, emphasizing the necessary balance between a child's need for exploring independence and seeking comfort from a caregiver.[10] At the top of the circle, there is the depiction of the caregiver's support of the child's autonomy and mastery in navigating the world independently. The caregivers acts as a secure base for the child rely on and look towards as a source of guidance. The circle continues onto the bottom half where the caregivers' play the role as comforting the child when in need or protection or warmth. If parents are balanced on both sides of the circle, they resemble parent-child relationships that are secure and organized. If there is not a balance, there is a limited circle of security, placing restrictions on the parent-child relationships.[11] These limited circles yield insecure, disorganized parent-child attachments. The protocol has so far been aimed at and tested on preschoolers up to the age of 4 years.

The main goal of the intervention is to help caregivers become "Bigger, Stronger, Wiser, and Kinder".[12] This phrase has served as the tagline for Circle of Security, highlighting the main tenets of the intervention. These goals can be summarized in these key aims:

  1. To increase the caregivers sensitivity and appropriate responsiveness to the child’s signals relevant to its moving away from to explore, and its moving back for comfort and soothing;
  2. To increase their ability to reflect on their own and the child’s behavior, thoughts and feelings regarding their attachment – caregiving interactions; and
  3. To reflect on experiences in their own histories that affect their current caregiving patterns. This latter point aims to address the miscuing defensive strategies of the caregiver.[13]

Its four core principles are: that the quality of the child parent attachment plays a significant role in the life trajectory of the child; that lasting change results from parents changing their caregiving patterns rather than by learning techniques to manage their child's behaviors; that parents relationship capacities are best enhanced if they themselves are operating within a secure base relationship; and that interventions designed to enhance the quality of child–parent attachments will be especially effective if they are focused on the caregiver and based on the strengths and difficulties of each caregiver/child dyad.[14]

The intervention puts a focus on the primary caregiver and the child. There is an initial assessment which utilizes the 'Strange Situation' procedure, (Ainsworth 1978), observations, a videotaped interview using the Parent Development Interview (Aber et al. 1989) and the Adult Attachment Interview (George et al. 1984) and caregiver questionnaires regarding the child. The child's attachment pattern is classified using either Ainsworth or the PAC (Preschool Attachment Classification System). The therapy is then 'individualized' according to each dyad’s attachment/caregiver pattern. The program consist of 20 weekly sessions that last 75 minutes. Sessions are in groups with no more than 6 parent-child dyads. The small group setting allows caregivers to observe and learn from their peers as well as maintain an individualized treatment plan.[15] The actual therapy consists of video feedback vignettes and psycho-educational and therapeutic discussions. Caregivers learn, understand and then practice observational and inferential skills regarding their children's attachment behaviors and their own caregiving responses. To capitalize on this user-friendly system in the intervention, therapists developed the "shark music" tool. During the video feedback clips, intense music (shark music) is played when there is problematic behavior exhibited by the caregiver or child. The music is meant to noticeably point out triggering behavior for the caregivers of the group to witness. Not all caregivers view certain behaviors as problematic, so this makes it clear for them to see what is okay and not okay.

The therapist is able to analyze the caregiving style of each dyad through the initial assessment. From this, the therapist creates a personalized treatment plan based on the sensitivity the parent expresses. The Circle of Security intervention plan notes that there are three sensitivities that are seen in caregivers. Many can express more than one, but there is always one sensitivity that is more prevalent than others.[16][17]

Separation sensitivity is when a caregiver has particular difficulty with being separated from others or being autonomous because they believe that separation precedes abandonment.[4] Caregivers also believe that to avoid experiences where they may be abandoned, they must comply with what others, their children included, want and need while devaluing their own wants and needs. This makes serving as a place of comfort as well as a secure base for children difficult. If the caregiver perceives their child’s desire for exploration as separation, then they will encourage behaviors that foster dependence on them. Similarly, when their child needs regulation through discipline, the caregiver may perceive setting boundaries as creating a conflict and due to their need to have connection with their child as their own source of comfort, they become unable to properly set restrictions in their relationship as well.

Esteem sensitivity is when a caregiver believes that they cannot be accepted by just being themselves, and that as a result they are not valued in relationships. In order to decrease their likelihood of being judged or abandoned as a result, they are desperate to illustrate that they are very special or worthy of praise because of exceptional qualities that their children have or their achievements. As a result of a fierce need for their children’s perceived perfection, they often continuously encourage exploration, but do not provide the place of comfort that their children need because that as seen as acquiescing to imperfect behavior .

Safety Sensitivity comes from when a caregiver believes growing close to their child means that they will lose the ability to control their own life due to forced acquiescence to the desires and needs of their children. This arises when caregivers struggle with intimacy and leads to them enforcing their own isolation so that they will not be engulfed by the intrusions of others in general and especially by the intense emotions of their children. Children of these parents will often be forced to explore because they cannot develop closeness with their caregivers, and from this they do not have the place of comfort that they need.

In order for this intervention to be effective, the therapist must build a comfortable and trusting relationship with the caregiver. This trusting relationship between therapist and caregiver addresses attachment or trust issues that the caregiver may have experienced in their past. It is pertinent for these lingering issues to be resolved so that the caregiver can be a present and healthy support for the child. Therapists follow a three part process to form a healthy, trusting bond with their clients: R-A-R [17]

  1. R- Relationship: The therapist-caregiver relationship is the foundation of the intervention. This relationship is the main focus of the intervention in order for the treatment to be effective.
  2. A- Affect Regulation: The therapist helps to coregulate the potentially difficult emotions the parents may face throughout the treatment. By doing so, caregivers learn how they can serve as this coregulator for their children after therapy.[18]
  3. R- Reflection: The therapist creates a secure environment for the parents in the group to reflect together and alone on their relationship with their children.[16]

Circle of Security is being field tested within the 'Head Start'/'Early Head Start' program in the USA. According to the developers the goal of the project is to develop a theory- and evidence-based intervention protocol that can be used in a partnership between professionals trained in scientifically based attachment procedures, and appropriately trained community-based practitioners.[13] It is reported that preliminary results of data analysis of 75 dyads suggest a significant shift from disordered to ordered patterns, and increases in classifications of secure attachment. It is noted that dyads that are more at risk beginning treatment show greater results from the treatment.[19] Dyads starting as insecure and disorganized were seen to progress in one of the two relationship categories by the end of the intervention.[20] However, the process of validation is not yet completed.[21]

Attachment and Biobehavioral Catch-Up (ABC)

Attachment and Biobehavioral Catch-Up (ABC) is a parenting intervention for primary caregivers of infants or toddlers who have experienced early adversity such as abuse, neglect, poverty, and/or placement instability. It is a 10-week long intervention that consists of 10 one-hour sessions conducted on a weekly basis. Each session is led by a certified parent-coach and occurs at home.

The 3 goals of the intervention are to:

  1. Increase nurturing behaviors of the caregiver
  2. Enhance the caregiver's ability to follow the child's lead with delight
  3. Decrease potentially harsh or frightening behaviors of the caregiver

The ability of young children to regulate their behaviors, emotions, and physiology is strongly associated with the quality of the relationship they have with their caregiver.[22] By changing the caregiver's behavior, ABC also seeks to help young children enhance their behavioral and regulatory capabilities. Studies have shown that ABC improves child attachment quality,[23] increases caregiver sensitivity to child's behavioral signals,[24] and boosts children's executive functioning.[25] While it was originally developed by Dr. Mary Dozier at the University of Delaware for caregivers of infants ages 6–24 months (ABC-Infant), it has since been expanded to include toddlers ages 24–48 months (ABC-Toddler).

The Bakermans-Kranenburg, Van IJzendoorn and Juffer meta analysis (2003)

This was an attempt to collect and synthesise the data to try to come to "evidence-based" conclusions on the best intervention practices for attachment in infants. There were four hypotheses:

  • Early intervention on parental sensitivity and infant attachment security is effective.
  • Type and timing of programme makes a difference.
  • Intervention programmes are always and universally effective.
  • Changes in parental sensitivity are causally related to attachment security.

The selection criteria were very broad, intending to include as many intervention studies as possible. Sensitivity findings were based on 81 studies involving 7,636 families. Attachment security involved 29 studies and 1,503 participants. Assessment measures used were the Ainsworth sensitivity rating, Ainsworth et al. (1974), the Home Observation for Measurement of the Environment, Caldwell and Bradley (1984), the Nursing Child Assessment Teaching Scale, Barnard et al. (1998) the Erickson rating scale for maternal sensitivity and supportiveness, Egeland et al. (1990).

The conclusion was that "Interventions with an exclusively behavioural focus on maternal sensitivity appear to be most effective not only in enhancing maternal sensitivity but also in promoting children's attachment security." p212.[26]

Three studies were singled out by Prior and Glaser to illustrate intervention processes which have shown good results. p239-244.[21]

"Watch, wait and wonder", Cohen et al. (1999)

This intervention involved mothers and infants referred for a community health service. Presenting problems included feeding, sleeping, behavioural regulation, maternal depression and feelings of failure in bonding or attachment. The randomly assigned control group undertook psychodynamic psychotherapy.

The primary work is between mother and therapist. It is based on the notion of the infant as initiator in infant–parent psychotherapy. For half the session the mother gets down on the floor with the infant, observes it and interacts only on the infant's initiative. The idea is that it increases the mother's sensitivity and responsiveness by fostering an observational reflective stance, whilst also being physically accessible. Also the infant has the experience of negotiating their relationship with their mother. For the second half the mother discusses her observations and experiences.

Infants in the watch, wait and wonder group were significantly more likely to shift to a secure or organised attachment classification than infants in the psychodynamic psychotherapy group although there was no differential treatment effect in maternal sensitivity. It has been pointed out however that specific caregiver responses to attachment (the precursors to secure attachments) were not measured.[21][26]

"Manipulation of sensitive responsiveness", van den Boom (1994) (The Leiden Programs)

This intervention focused on low socio-economic group mothers with irritable infants, assessed on a behavioural scale. The randomly assigned group received 3 treatment sessions, between the ages of 6 and 9 months, based on maternal responsiveness to negative and positive infant cues. Intervention was based on Ainsworth's sensitive responsiveness components, namely perceiving a signal, interpreting it correctly, selecting an appropriate response and implementing the response effectively.

It was found that these infants scored significantly higher than the control infants on sociability, self soothing and reduced crying. All maternal components improved. Further, a 'strange situation' assessment carried out at 12 months showed only 38% classified as insecure compared to 78% in the control group.

Follow ups at 18, 24 and 42 months using Ainsworth's Maternal Sensitivity Scales, the Bayley Scales of Infant Development, the Child Behaviour Checklist (Achenbach) and the Attachment Q-sort showed enduring significant effects in secure attachment classification, maternal sensitivity, fewer behaviour problems, and positive peer relationships.[27][28]

"Modified interaction guidance", Benoit et al. (2001)

This intervention aimed to reduce inappropriate caregiver behaviours as measured on the AMBIANCE (atypical maternal behaviour instrument for assessment and classification). Such inappropriate behaviours are thought to contribute to disorganized attachment. The play focused intervention (MIG) was compared with a behaviour modification intervention focused on feeding. A significant decrease in inappropriate maternal behaviours and disrupted communication was found in the MIG group.[29]

Feedback methods

Videofeedback intervention to promote positive parenting (VIPP)

Developed and evaluated by Juffer, Bakermans-Kranenburg and Van IJzendoorn, this collection of interventions aim to promote maternal sensitivity through the review of taped infant–parent interactions and written materials. The programme can also be expanded to include the parents internal working models (VIPP-R) and/or sensitive disciplinary practices (VIPP-SD). Findings from randomized controlled trials are mixed but overall supportive of efficacy, particularly for "highly reactive infants" and in reducing later externalising behaviours. The various versions show promise but research continues.[30]

Clinician assisted videofeedback exposure sessions (CAVES)

Developed by Daniel Schechter and colleagues. They developed an experimental paradigm informed by attachment theory called the Clinician Assisted Videofeedback Exposure Sessions to test whether traumatized mothers, who often suffered psychological sequalae from a history of abuse and violence, could "change their mind" about their young children. The technique used was to watch video-excerpts of play, separation and similarly stressful moments in the presence of a clinician who asks the mother to think about what she (and her child) might be thinking and feeling at the time of the excerpt and at the moment of videofeedback. It applies the principles of mentalization as an aide to emotional regulation with these traumatized parents.[31][32] It also involves elements of prolonged exposure treatment,[33] the video-based treatment Interaction Guidance,[34] and psychodynamically-oriented child–parent psychotherapy.[35] Schechter and colleagues showed a significant change in the way mothers perceived their own child and their relationship together.[36]

VIG (video interaction guidance)

In video interaction guidance the client is guided to analyse and reflect on video clips of their own interactions (e.g. a mother with her infant).[37] Research results include that VIG enhances positive parenting skills, decreases/alleviates parental stress and is related to more positive development of the children.[38][39] VIG is recommended by NICE in the UK.[40]

Public health programs

Tamar's Children

This is a scheme in which a version of the Circle of Security intervention was added to a jail diversion program for pregnant women with a history of substance abuse. Preliminary data indicates a 68% rate of secure infant–mother attachment in the first relatively small (19) sample. This is a rate of secure attachment typically found in low risk samples.[1]

Florida Infant Mental Health Pilot Program

This project tested the provision of 25 sessions of child–parent psychotherapy (see above) for mothers investigated or substantiated for child maltreatment through court-based teams. There were no further reports of maltreatment by participants during and immediately after the programme and positive changes in maternal and child behaviours were noted. The advocacy organisation Zero to Three is supporting such teams being established in other states.[41]

Foster care interventions

New Orleans Intervention/Tulane Infant Team

This is a foster care intervention devised by J.A. Larrieu and C.H Zeanah in 1998.[42] The program is designed to address the developmental and health needs of children under the age of 5 who have been maltreated and placed in foster care. It is funded by the state government of Louisiana and private funds. It is a multidisciplinary approach involving psychiatrists, psychologists, social workers, paediatricians and paraprofessionals—all with expertise in child development and developmental psychopathology.

The aim of the intervention is to support the building of an attachment relationship between the child and foster carers, even though about half of the children eventually return to their parents after about 12 to 18 months. The designers note Mary Doziers program to foster the development of relationships between children and foster carers (ABC) and her work showing the connection between foster children's symptomology and foster carers attachment status. Work is based on findings that the qualitative features of a foster parents narrative descriptions of the child and relationship with the child have been strongly associated with the foster parents behavior with the child and the child's behavior with them.[43] The aim was to develop a programme for designing foster care as an intervention.

The theoretical base is attachment theory. There is a conscious effort to build on recent, although limited, research into the incidence and causes of reactive attachment disorder and risk factors for RAD and other psychopathologies.

Soon after coming into care the children are intensively assessed, in foster care, and then receive multi modal treatments.[44] Foster carers are also formally assessed using a structured clinical interview which includes in particular the meaning of the child to the foster parent. Individualised interventions for each child are devised based on age, clinical presentation and information on the child/foster carer match. The assessment 'team' remains involved in delivering the intervention. Those running the programme maintain regular phone and visit contact and there are support groups for foster parents.

Barriers to attachment are considered to be as follows;

  • The disturbed nature of the child's relationship with its parent(s) before their removal by the state. Serious relationship disturbances are considered likely to be important contributors to difficulties in establishing new attachment relationships. Psychiatric and substance abuse histories and other criminal activities are common. Developmental delays in the children are common and there is a considerable range of regulatory, socioemotional and developmental problems. The child may perceive relationships as inconsistent and undependable. Further, despite harsh and inconsistent treatment many of the children remain attached to their parents, complicating the development of new attachment relationships.
  • Foster parents may also present barriers to forming healthy attachment relationships. Based on Bowlby, the caregiving system is seen as a biobehavioral system in adults that is complementary to the child's attachment system. Not all foster carers have this strong biological disposition as many fear becoming too 'attached' and suffering loss, many are effectively doing it to earn money and some perceive such children as 'damaged goods' and may remain emotionally distant and under involved.

Interventions include supporting foster parents to learn to help the child in regulating emotions, to learn to respond effectively to the child's distress and to understand the child's signals, especially 'miscues' as the signals of such children are often confusing as a consequence of their often frightening, inconsistent and confusing past relationships. Foster carers are taught to recognize what such children actually need rather than what they may appear to signal that they need. Such children often exhibit provocative and oppositional behaviors which may normally trigger feelings of rejection in caregivers. Withdrawn children may be overlooked and seemingly independent, indiscriminate children may be considered to be managing much better than they are. Foster carers are regularly contacted and visited to assess their needs and progress.

(As of 2005), 250 children had participated in the programme. Outcome data published in 2001 revealed a 68% reduction in maltreatment recidivism for the same child returning to its parent(s)and a 75% reduction in recidivism for a subsequent child of the same mother. The authors claim the programme not only assists the building of new attachments to foster parents but also has the potential impact a families development long after a returned child is no longer in care.[45]

Differentiation from attachment therapy

It is critical to differentiate therapies based on attachment theory from the "unfortunately named" attachment therapy.[46] (However, the use of the terms "attachment therapy" and "attachment-based therapy" is not consistent in literature and on the Internet). Attachment therapy, also known as 'holding therapy', is a group of unvalidated therapies characterized by forced restraint of children in order to make them relive attachment-related anxieties; a practice considered incompatible with attachment theory and its emphasis on 'secure base'.[2] The conceptual focus of these treatments is the child's individual internal pathology and past caregivers rather than current parent-child relationships or current environment.[47] This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with which it is considered incompatible.[2][48] In 2006, the American Professional Society on the Abuse of Children (APSAC) Task Force reported on the subjects of attachment therapy, reactive attachment disorder, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorders.[47] The Taskforce was largely critical of attachment therapy's theoretical base, practices, claims to an evidence base, non-specific symptoms lists published on the internet, claims that traditional treatments do not work and dire predictions for the future of children who do not receive attachment therapy. The controversy also extends to the theories, diagnoses, diagnostic practices, beliefs, and social group norms and patient recruitment and advertising practices.[47]

See also


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