Attachment in Adolescence: An Agenda for Research and Intervention

1. Attachment in Adolescence: An Agenda for Research and Intervention Ronald Jay Werner-Wilson, Ph.D. based on Material from Developmental-Systemic Family Therapy with Adolescents (Werner-Wilson, 2001)

2. Reference A version of this material was published as Werner-Wilson, R. J. & Davenport, B. R. (2003). Distinguishing between conceptualizations of attachment: Clinical implications in marriage and family therapy. Contemporary Family Therapy, 25, 179-193.

3. Introduction “Attachments lie at the heart of family life. They create bonds that can provide care and protection across the life cycle (Ainsworth, 1991), and can evoke the most intense emotions - joy in the making, anguish in the breaking - or create problems if they become insecure” (Byng-Hall, 1995, p. 45).

4. Conceptual Confusion about Attachment • The word "attachment" is used casually and by professionals in a variety of ways that can create conceptual confusion. • It is a term that is used casually to refer to a general level of affection. • Professional Uses: • DSM: Reactive Attachment Disorder (a/k/a attachment disorder) • Influence of John Bowlby: • Attachment in children • Adult nuclear family attachment • Adult romantic attachment

5. Clinical Conceptualization of Attachment

6. Common Clinical Usage • “Attachment disorder” has become a popular clinical diagnosis for children. • “Attachment disorder” is described in ways that suggests it is a trait of the child. • “These seriously disturbed children have difficulty forming attachments even when placed in good foster and adoptive homes” (Booth & Wark, 2001, p. 5). • Children are often described as incapable of forming attachment bonds.

7. Diagnostic and Statistical Manual of Mental Disorders • Clinical use of the term attachment seems to be associated with the DSM diagnosis Reactive Attachment Disorder. • Some clinicians also seem to adopt some aspects of disorganized attachment. • Reactive Attachment Disorder of Infancy or Early Childhood is described in DSM as a “[m]arkedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years”

8. Reactive attachment disorder is demonstrated by either ... • “persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilent, or highly ambivalent and contradictory responses” • or “diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers …)” (DSM-IV-TR Quick Reference, pp. 78-79).

9. Characteristics of Reactive Attachment Disorder • According to DSM, reactive attachment disorder is associated with at least one of the following: • persistent disregard for basic emotional needs; • persistent disregard for basic physical needs; • repeated changes of primary caregiver (DSM-IV-TR Quick Reference, p. 79).

10. Reactive Attachment Disorder: Epidemiology • No studies have been conducted to establish prevalence, incidence, or natural course. • DSM simply states that it is very uncommon. • Some have inferred prevalence from child maltreatment statistics, but these are unreliable. • Abuse or neglect does not automatically produce Reactive Attachment Disorder.

11. Treatment of Attachment Disorder(from Hanson & Spratt, 2000) • Assumption: child has repressed rage which interferes with ability to form an attachment. • Clinical intervention: help child release her/his rage and teach child that parents can and will be in control. • “Parents may be told that this is the only way to keep their child from becoming a serial killer, murderer, or psychopath” (p. 142). • Parents may be told that conventional treatments will not work for their child. • Treatment includes Gestalt-type enacting and fighting with the child’s birth mother.

12. Holding Therapy • Also referred to as attachment or rage reduction therapy. • Confrontational model that uses coercive techniques to provoke emotional responses in the diagnosed child.

13. Three Primary Treatment Components • Prolonged restraint for purpose other than protection. • Prolonged noxious stimulation (e.g., tickling, poking ribs). • Interference with bodily functions.

14. Concern about Treatment “This restraining is not related to child’s immediate behavior, and the procedure may be repeated daily. During the restraining period, the clinician actively attempts to provoke and arouse the child by providing noxious stimulation such as yelling in the child’s face, poking or tapping the child, tickling, or pulling on limbs. The child may try to resist by screaming, fighting, or crying but eventually breaks down. When the child reaches the point of surrender, he is then given to his caregiver(s), to whom he reportedly instantly attaches” (Hanson & Spratt, 2000, p. 142)

15. Research on Treatment of Reactive Attachment Disorder • Hanson and Spratt (2000) recently completed a review of Reactive Attachment Disorder because of concerns about the “emergence of novel treatments that lack a sound theoretical basis or empirical support, and may potentially be traumatizing and harmful to the child”. • “Diagnosis is complicated by the fact that frequently there are comorbid mental health, medical, and developmental conditions that need to be assessed and treated.” • No treatments put forth for the disorder have been empirically examined for “safety or effectiveness” (p. 137).

16. “Major Concern” with Holding Therapy (Hanson & Spratt, 2000) • Child clients are particularly vulnerable, especially if they have severe abuse or neglect histories. • Attachment /Holding therapy could be traumatic. • Although proponents of attachment contend that it has been misrepresented (e.g., they suggest that it is also nurturing and sensitive), effectiveness seems to be based on anecdotal testimonials from parents. • “[T]he fact remains that there is simply no empirical evidence at present to support the assertion that attachment therapy is more effective, or even as effective, compared to accepted and conventional approaches” (p. 142).

17. Attachment Conceptualizations Associated with Bowlby

18. Areas of Investigation • Attachment in Children (measured via the strange situation and in-home observations) • Adult Nuclear Family Attachment (measured by the adult attachment interview) • Adult Romantic Attachment (measured using several self-report techniques)

19. An Evolutionary Perspective • Proximity to parents facilitates protection of children. • Infants are predisposed to seek proximity during distress. • Attachment, therefore, contributes to evolutionary survival. • “Within this framework, attachment is considered a normal and healthy characteristic of humans throughout the lifespan, rather than a sign of immaturity that needs to be outgrown” (Cassidy, 1999, p. 5).

20. Attachment is not … • imprinting • a fixed characteristic or attribute • adolescents demonstrate different attachment styles with different caregivers • attachment style may change throughout development

21. Attachment … • describes an emotional bond. • describes a set of behaviors that influence relationships. • is only one feature of the parent-adolescent relationship. • occurs in all children and youth. • style is based on an internal working model (set of expectations about relationships).

22. Behavioral Systems that Influence Attachment • Attachment Behavioral System • Repertoire of attachment behaviors. • Promotes proximity to caregiver. • Attachment occurs even when physical needs are not met or the child is abused. • The attachment behavioral system is a goal-corrected system that is flexible. • Exploratory Behavioral System • Promotes survival because curiosity helps adolescent children learn about and adapt to their environment. • This system reduces attachment behavior.

23. Behavioral Systems (cont.) • Fear Behavioral System • Promotes safety. • Engages the attachment system. • The Caregiving System • Parent repertoire of behaviors that are engaged to respond to attachment-seeking in children. • Like other systems, it is activated by internal and external cues.

24. Behavioral Systems (cont.) • The Sociable System • “[T]he organization of the biologically based, survival-promoting tendency to be sociable with others” (Cassidy, 1999, p. 9). • This system is different from the attachment system.

25. The Attachment Bond • Attachment bond refers to an affectional tie: “this bond is not between two people; it is instead a bond that one individual has to another individual who is perceived as stronger and wiser … A person can be attached to a person who is not in turn attached to him or her” (Cassidy, 1999, p. 12). • The attachment bond cannot be inferred from the presence or absence of attachment behavior.

26. Propositions About Attachment Bond (from Cassidy, 1999) • The attachment bond is only one feature of a parent-child relationship. Caregivers also serve as playmates, teachers, and disciplinarians. • Children experience multiple attachments but the quality of the attachment bond is not the same in each relationship. The quality of the bond is influenced by amount of interaction, quality of care provided, and emotional investment of the caregiver.

27. Early Attachment and Later Development (Thompson, 1999) • There seems to be a “modest” relationship between early attachment and later outcomes. • Influence of attachment seems to be “more contingent and provisional than earlier expected” (Thompson, 1999, p. 280). • Intervening events seem to moderate influence of attachment. • Thompson reminds us that attachment is only one dimension of the parent-child relationship. He noted that Bowlby recognized this as well.

28. Internal Working Models • Experiences with caregivers influence expectations about future relationships. • Working models seem to be “based on a network of developing representations that emerge successively but interactively with age (from Thompson, 1998). • Early representations provide important information but they are fairly simplistic and “ probably do not provide the conceptual foundation for the sophisticated and complex representations of self and relationships in other years” (Thompson, 1999, pp. 267-268).

29. Representational Systems Four interrelated conscious and unconscious representational systems seem to influence internal working models: • Social expectations about caregivers developed during the first year are subsequently elaborated. • Event representations: beginning in the third year, general and specific memories about attachment experiences are stored. • Beginning at age four, individuals begin to create their own narratives and self-understandings about self and relationships. • Beginning in the third and fourth years, the individual begins to form conclusions about characteristics of others and relationship expectations.

30. Significance of Developmental Processes on Attachment • Working models are continuously revised and updated throughout development • “[T]heir impact on a child’s psychosocial functioning at any particular age may depend on the security of the representations that are developed at that particular time” (Thompson, 1999, p. 268). • “[D]ifferent facets of working models (e.g., social expectations, autobiographical memory) have not only different developmental timetables but perhaps also different periods of critical influence.

31. Significance of Developmental Processes on Attachment (cont.) • Caregivers not only influence attachment by the quality of care they provide but also by the interpretation of that care because their interpretation may be adopted by the child. • Thompson (1999) concludes that, for these reasons, it is important to consider working models in a developmental context in order to understand them as a source of developmental continuity.

32. Multiple Attachments • Children form more than one attachment and strength of attachment seems to be influenced by the extent to which the caregiver provides sensitive care. • The potential number of attachment figures is not limitless. • Although children have multiple attachment figures, they do not treat all attachment figures as equivalent.

33. Individual Differences • Although there is a biological basis for attachment and all children become attached (even to abusive parents), not all children become securely attached. • “Secure attachment occurs when a child has a mental representation of the attachment figure as available and responsive when needed. Infants are considered insecurely attached when they lack such a representation” (Cassidy, 1999, p. 7). • Influences on Attachment • Context • Emotion • Cognition

34. Attachment: The Role of Emotion • Intense emotions are associated with the “formation, the maintenance, the disruption, and the renewal of attachment relationships” (Cassidy, 1999, p. 6). • Emotions contribute to motivation to seek attachment.

35. Attachment: The Role of Cognition • Children learn to use specific attachment behaviors with specific people in specific situations. • Children develop “internal working models” that help them anticipate the future.

36. Attachment: The Role of Context • Activation of the attachment behavioral system is influenced by • conditions in the child • conditions in the environment. • “In sum, proximity seeking is activated when the infant receives information (from both internal and external sources) that a goal (the desired distance from the mother) is exceeded. It remains activated until the goal is achieved, and then it stops” (Cassidy, 1999, p. 6).

37. Family as a Secure Base • Definition: “a family that provides a reliable and readily available network of attachment relationships, and appropriate caregivers, from which all members of the family are able to feel sufficiently secure to explore their potential” (Byng-Hall, 1999, p. 627).

38. Factors Associated With a Secure Family Base • There is a shared awareness that attachment relationships are important and care for others is a priority in the family. • Family members should support one another in providing care for each other.

39. Factors that Undermine a Secure Base in Families • Fear of losing an attachment figure or actual loss of an attachment figure. • A child clings to one caregiver and rejects relationships with other caregivers. Byng-Hall refers to this as “capturing” an attachment figure. • Turning to an inappropriate attachment figure (i.e., if one parent is not supporting the other parent, a child may be used as an attachment figure). • Abusive relationships. • Negative self-fulfilling prophecies: there is an expectation that losses from other generations will be repeated.

40. Attachment in Adolescence • “Research is increasingly showing that adolescent autonomy is most easily established not at the expense of attachment relationships with parents but against a backdrop of secure relationships that are likely to endure well beyond adolescence” (Allen & Land, 1999, p. 319). • During adolescence, attachment relationships are gradually transferred to peers.

41. Problems Associated with Adolescent Attachment • Caregivers may interpret individuation efforts as a threat to their relationship with their adolescent children. • Insecurely attached adolescents and their parents may become overwhelmed by affect associated with individuation which, in turn, contributes to conflict. • Insecurely attached adolescents may become easily frustrated because they do not expect to be heard or understood by their parents. • Caregiver seems to demonstrate more rejecting behaviors toward adolescent. • Adolescent demonstrates more anger at home than in the other settings. • Play (exploratory) behavior seems to serve as a distraction from attachment needs.

42. Attachment Styles in Children • Avoidant • Resistant or Ambivalent • Disorganized/Disoriented • Secure

43. Avoidant Attachment

44. Characteristics of Avoidant Attachment • Avoidant attachment is associated with a high degree of physiological arousal. • Adolescent engages in behaviors to distract or soothe her/himself in response to stress or anxiety. • Internal working model: caregiver is unresponsive and rejecting. • Adolescent appears to avoid interacting with parent and acts indifferent.

45. Characteristics of Avoidant Attachment (cont.) • Caregiver seems to respond negatively to the adolescent’s attempts to make contact: the caregiver withdraws when the adolescent is sad. • Caregiver seems to demonstrate more rejecting behaviors toward adolescent. • Adolescent demonstrates more anger at home than in the other settings. • Play (exploratory) behavior seems to serve as a distraction from attachment needs.

46. Presenting Problems Associated with Avoidant Attachment • Withdrawal as a coping behavior may lead to social isolation. Adolescent may run away from home. • Soothing behavior may lead to substance abuse as a way to self-medicate. • Irritability may be mis-diagnosed as Conduct Disorder. • Avoidant child is likely to engage in delinquent activities. • Distraction attempts that rely on stimulation may be may be mis-diagnosed as ADD/ADHD.

47. Treatment Implications for Avoidant Attachment • Adolescent may respond in aggressive or antagonistic ways toward therapists and other authority figures. • Assess parenting style. Promote authoritative/democratic parenting. • Interventions that are experienced by adolescent as punitive may provide confirmation to the adolescent of an internal working model based on rejection. • Consequences or structuring interventions should include attempts to validate and nurture.

48. Resistant or Ambivalent Attachment

49. Characteristics of Resistant or Ambivalent Attachment • Consistent with enmeshed relationships. • Adolescent does not seem to be soothed by the presence of her/his caregiver and may appear angry or passive. • Caregiver seems committed to the task of nurturing but is often emotionally unavailable. • Caregiver seems to be preoccupied with past relationship experiences and may appear angry.

50. Characteristics of Resistant or Ambivalent Attachment (cont.) • Internal working model of adolescent: caregiver is capable of responding if s/he is persistent at seeking attention. • Some children may take care of their parent as a way to foster interaction. This may, according to Byng-Hall (1995), contribute to parentification of child.