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Liss V.

Mariano, MD

Attachment is an affectional tie that forms with another specific person, a tie that endures over time and ultimately becomes a part of an individuals psychic structure. Bowlby, John

Attachment phenomena are common in birds and mammals, with extended dependency periods in which offspring are fed, cleaned, sheltered and protected by the parent. In many species, attachment is enhanced by imprinting, a learned attachment that forms at the earliest phases of development. Imprinting is most likely to occur during specific, critical periods of development. If imprinting is not achieved during those times, it is difficult to attain.

Attachment facilitates survival of the offspring, and investment in parental care for offspring is theorized to involve a cost benefit trade off. The increased likelihood that offspring will survive is weighed against potential costs of parental care.

In humans, emotional attachments to familiar caregivers are apparent between 6-12 months of age as infants construct expectations for the behavior of other people. This helps them to become more socially and behaviorally competent.

Attachment shapes social behavior and emerging working models of the self, others, and relationships. Before representational capacities have consolidated, young children rely on the harmony of their relationships with parents to develop and maintain positive working models of self and relationships. Working models that are based on early interactions with the primary caregiver are then incorporated in a network of selfreferential beliefs that older children construct leading to states of mind and the capacity to mentalize.

Infants greet the parents return with obvious pleasure Reflect confidence that the parent will be responsive to them Mothers of secure infants are sensitive to their babies signal; they are attuned to the mind of the child The infants would communicate their needs and the mothers would respond to this -- contingent communication Reflected the presence of mentalizing capacity in the mother

Infants conspicuously avoid the parent during reunions Seem indifferent to their mothers absence Mothers of avoidant infants previously rebuffed their babies They were perceived to be rejecting and emotionally unavailable

Infants combine contactseeking activities with angry, rejecting reunion behavior Mothers of ambivalent infants had an inconsistent parenting style. They were too preoccupied to recognize their babys needs.

Infants displayed incoherent, confused, or inconsistent behaviors freezing, collapsing Mothers were noted to be abusive, neglectful, and tended to react to their childrens behavior with confusion or fright

The quality of the infantmother attachment reflects both maternal sensitivity and infant security. A secure attachment predicts a more cooperative, harmonious parent-child relationship in future years.

Securely attached children are more responsive to socialization efforts. They see themselves and others more constructively and have more sophisticated emotional and moral understanding.

For insecure attachments, the mother is seen by the child both as a safe haven and a source of danger.

Insecure attachment is a marker of a disturbed caregiving relationship and is considered a significant etiologic factor for psychopathology.

These attachments were reflections of uncertainty or ambivalence concerning the parents helpfulness following stressful situations, or an expectation that the parent will be unhelpful upon her return.

Insecurely attached children are more likely to manifest with fearfulness, hypervigilance, indiscriminate sociability, aggressiveness, blunted emotional responsiveness, affect dysregulation, and markedly ambivalent behavior.

Early attachment foreshadows later developmental outcomes primarily when there is consistency in caregiving influences over time. Factors which can influence an infants sense of security other than attachment include
The caregiving involvement of the father Extent of parental satisfaction with the marital relationship Impact of socioeconomic stress on the family Social support to the mother Infants temperament

Attachment security can change in response to financial, legal, and social stress in the family, as well as significant transitions in caregiving arrangements for the baby. The risk for psychopathology is highest when multiple factors coincide to increase the childs anxiety about his parents availability. (Kobak, 1999).

The foundations of early mental health are further damaged when the child cannot rely on the parents willingness and competence to protect them.

Insecure attachment patterns have been consistently documented in up to 90% of maltreated children.

Because young children have limited coping skills, they are particularly at risk for negative outcomes associated with traumatic events.

Consistent failures in the parents ability to identify and respond supportively to the childs developmental needs and temperament may lead to rigid self-protective mechanisms that interfere with emotional closeness.
Insecurely attached children are more likely to interpret even temporary disruptions as severe threats. This may lead to further decreased emotional expressiveness, avoidance, withdrawal, controlling behavior, anger, and aggression.

This may signify the childs loss of trust in the parents competence as a protector.

Complex trauma exposure results in a loss of core capacities for self-regulation and interpersonal relatedness. In the setting of an insecure attachment style, children become distressed easily and do not learn to collaborate with others when their own internal resources are inadequate.

Survival based behaviors that are rigid, extreme, and dissociative are constantly used as an attempt to neutralize themes of helplessness, abandonment, betrayal, and rejection.

The more repeated and pervasive the trauma exposure, particularly if with prepubertal onset, the more likely it is that the child will show generalized and chronic disturbances in the future.
Data from the Netherlands Study of Depression and Anxiety revealed that the presence of childhood trauma predisposes to a more chronic course of depression. The greater the number of childhood traumas the person reported, the higher the probability of lifetime chronicity.

This may be compounded by additional risk factors such as poverty, community violence, and lack of access to community resources, as well as perinatal insults such as hemorrhage or hypoxic injury.

Numerous studies of traumatized children found problems with unmodulated aggression and impulse control, attentional and dissociative problems, and difficulty negotiating relationships. The host of psychiatric problems associated with childhood adversity is myriad and include affective, anxiety, dissociative, and substance abuse disorders as well as Axis II disorders.

Resilience is the study of individual differences in response to stress. In considering psychosocial adversity, it must be noted that contingencies occur within and across developmental periods. Affectionate and stable patterns of experience facilitate the childs ability to organize physio-psychological processes.

Having repeated experiences of being comforted when distressed is a part of developing ones own capacity for self-comfort and regulation. Later on, this becomes the capacity to provide the same to others.

Parents, as models for the child in the establishment of controls over impulse and behavior, make a significant contribution to the development of ego control and socialization. The formation of good peer relationships in middle childhood is in part dependent on attachment relationships during infancy, and can help mitigate the effects of psychosocial adversity.

The Child

The Adverse Event

Acute vs Chronic Intensity

The Social Environment

Availability of the parent or the other caregiver as a support Ability of the caregiver to help the child cope Level of family stress

Developmental Stage Proximity to the Traumatic Event


Injury / Loss to the Caregiver

Family stability
Social support from the environment

Developmental Delays

Extent of injury

Early in life, cognitive misconceptions about how events occur and the intense fear of losing the parent compound the impact of a traumatic event. When there are chronic, repetitive traumatic events such as separation or abuse, the child will experience a fear that assumes center stage for some period in his life, recedes as the child is able to acquire a coping mechanism to manage it, and emerge again as a reaction to future external events or emotional stressors. The most devastating effects of trauma are seen to stem from repeated, chronic situations that involve caregivers as perpetrators.

In the context of psychosocial adversity, poor social support, and an insecure attachment style, the child reflects impairments in core psychosocial competencies, including
Increased susceptibility to stress

Inability to regulate emotions without assistance

Altered helpseeking

Difficulty focusing attention and modulating arousal

Being easily overwhelmed by intense or numbed emotions Excessive dependency or social disengagement

Complex childhood trauma was more significantly associated with externalizing behavior problems and psychosocial impairment, regardless of the DSM-IV-TR diagnosis.

Affect regulation begins with accurate identification of internal emotional experiences.

Following the identification of the emotional state, the child must be able to express emotions safely and modulate or regulate internal experience.
Manifestations of dysfunction include dissociation, chronic numbing of emotional experience, dysphoria, avoidance of affectively laden situations, and maladaptive coping strategies. These children therefore often present as emotionally labile, with extreme rapidly escalating responses to minor stress.

This requires the ability to differentiate between states of arousal, interpret these states, and apply appropriate labels. Deficits in the ability of maltreated children to discriminate among and label affective states in both self and others have been demonstrated.

Childhood adversity appears not only to increase risk for affective disorders, but also to predispose toward earlier onset, longer duration, and poorer response to treatment.