Trauma and Child Attachment Representation The Manchester Child Attachment Story Task (MCAST)

Transcription

1 Trauma and Child Attachment Representation The Manchester Child Attachment Story Task (MCAST) Jonathan Green University of Manchester, Manchester Academic Health Sciences Centre Royal Manchester Childrens Hospital Manchester, UK

2 Attachment theory Integration of ethological, evolutionary, systemic, psychodynamic and empirical approaches (Bowlby 1969, 1982, 1988). In distress infants selectively seek proximity to known adults for comfort using goal directed behaviours. Attachment behaviours alternate with exploratory behaviours. Early interactions around distress become internalised into an internal working model (IWM) of how distress can be assuaged, shaping perceptions, thought and behaviour (Main 1985, 1991).

3 Transactional model behaviour and internal states Other Factors Early Evolving Continuing Interactions Interactions Relationships Internal Representations (a) Internal Working Model (b) Biasing other relationships and behaviour

4 Why be interested in Attachment clinically? Theory of specific dyadic relationships Helps understand Motivational system of goal directed behaviour Affective responses in context Child mental state and social cognition

5 Patterns of attachment Patterns of attachment behaviour in toddlers and older children (Ainsworth et al 1979, ff) Secure (50-70%) Insecure (30+%) Avoidant (20-30%) Ambivalent (<10%) Disorganised (15-80%) Anomalous findings in the Strange Situation in infancy (Main and Solomon 1986/90) absence of strategy, simultaneous contradictory behaviours, freezing, dissociation, abnormal movements, fear of parent relationship specific in later childhood: bizarre, disorganised mental states controlling/solicitous behaviour with caregiver

6 Disorganisation and psychopathology Infancy: 15% low risk - 80% high risk (eg drug abuse, maltreatment, chronic maternal depression) in 80 studies (van IJzendoorn, et al 1999) Childhood Externalising disorder (Greenberg 1996, van IJzendoorn, et al 1999) Internalising disorder (Verschueren 2000) Adolesence Psychopathology (Carlson 1998) Clinical implications; D children are at high risk

7 Attachment and Trauma via parental behaviours Frightened or frightening parental behaviours place child attachment proximity seeking in a double bind (Main and Hesse 1990) Atypical maternal behaviours relate to child Attachment Disorganisation (Lyons Ruth et al (1999) Disrupted communication Affective errors (contradictory cues or non response) Role confusion Negative - intrusive Disorientation Common features - contradictory incompatible communication

8 Measuring attachment

9 SSP and AAI Strange Situation Procedure Focus on infant parent behaviour at reunion after distress Behavioural observation of goal directed behaviour Basic codes of Avoidant, Secure, Ambivalent Adult Attachment Interview Focus on adult narrative about attachment memory and themes Episodic and semantic memory systems Focus on narrative interruption and coherence Grice s maxims Basic codes of Dismissing, Autonomous, Preoccupied

10 Attachment Disorganisation in SSP and AAI SSP AAI absence of strategy, simultaneous contradictory behaviours, freezing, dissociation, abnormal movements, fear of parent controlling/solicitous behaviour in later childhood, bizarre representations U coding context specific interruptions in narrative flow Disorganisation of themes

11 Manchester Child Attachment Story Task (MCAST) Clinical development Scientific evaluation Jonathan Green, Charlie Stanley, Ruth Goldwyn Grateful acknowledgements to Bernadette Gannon, Jill Hodges, Mary Main, Eric Hesse, Nancy Kaplan, Peter Fonagy, Mary Target, Vicky Smith, Sarah Marzolini, Sarah Peters, Tom O Connor Support funding from Mental Health Foundation, Dept of Health, Wellcome Trust Subsequent studies beyond Manchester

12 MCAST - aims The evaluation of child s mental state with respect to attachment representation Application to clinical populations Focus on disorganisation Ability to investigate relationship with other domains of developmental difficulty/comorbidity eg attentional, social impairments; mood Relation to social cognition and psychopathology outcome

13 Methodology (Green et al 2000, Goldwyn et al 2000) Doll play vignette completion design 4 story stems relate to specific attachment stressors Single caregiver, child identified with dolls Emotional arousal Coding uses concepts and methods from both infancy and adult research Measures predominant strategy of assuagement, coherence using Grice s maxims, attachment classification, forms of disorganisation

14 Structure of MCAST vignettes Initiation phase Engagement Mood induction Handover Vignette completion Structured prompts Probes For mentalising/metacognition Closure

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19 Coding structure Identification of attachment behavioural cycle in story completion Behavioural codes Assuagement Predominant strategy of assuagement Coding of discourse coherence Coding of disorganisation Motivational conflict (SSP/D & AAI/U systems) Episodic and pervasive Disorganisation codes Contractictory/absent strategy; Lapses; Catastophising; bizarre themes Outcome codes: Attachment categories/d score/coherence score/security scale/mentalising-metacognition score Algorithm for combining vignettes to total coding

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21 Attachment Representation and Trauma

22 Attachment Dynamics in the Clinical Context (Green 1996) Personality Mental State CAREGIVER Attachment Representation Social Stress and Support Parental state of mind and behaviour CAREGIVER- CHILD INTERACTION Child state of mind and behaviour CHILD Attachment Representation Social Circumstances Developmental Factors Mental State

23 Attachment Disorganisation and parental loss and trauma Personality Mental State CAREGIVER Attachment Representation AAI Parental state of mind and behaviour Social Stress and Support CAREGIVER- CHILD INTERACTION SSP Child state of mind and behaviour CHILD Attachment Representation Social Circumstances MCAST Developmental Factors Mental State

24 Disorganised attachment associated with parental trauma/loss Infant disorganisation and unresolved loss or trauma in parent Linkage in 9 studies (van IJzendoorn 1995) 6 yr MCAST and concurrent maternal attachment (AAI) status UK (Goldwyn et al 2000, n=33); Child disorganisation associated with maternal unresolved loss and trauma (AAI/U) in adult (Kappa.6, p=.001) Child and mother coherence closely linked in the disorganised children (Kappa.6, p=.005) Italy (Zaccagnino et al n=44) D/U/D linkage (Kappa 0.5, p < 0.01); ABC/DsFE agreement 63% (Kappa 0.3, p < 0.03). Security/insecurity agree 70% (Kappa 0.4, p < 0.02) Clinical implications

25 Attachment Disorganisation and atypical parenting Personality Mental State CAREGIVER Attachment Representation Social Stress and Support Parental state of mind and behaviour CAREGIVER- CHILD INTERACTION SSP Child state of mind and behaviour CHILD Attachment Representation Social Circumstances MCAST Developmental Factors Mental State

26 Disorganisation and Maternal Expressed Emotion (Green et al 2007) EE (Camberwell Family Interview) Criticism its his attitude everyone s stupid bar James.. Hostility..right I ll stick you in a bloody well home sometimes I bloody well feel like it. Overinvolvement He s got control over me. Through guilt I feel sorry for him. I absolutely doted on him as a baby - I feel for him. Maternal EE associated with Disorganised Attachment Clinical sample externalising disorder (n=63) Green et al (2007), Very high maternal EE (critical comments + hostility + overinvolvement): relates to MCAST pervasive D (chi2 = 11.1, p=0.001) And independently to maternal depression (F=4.3, p=.047) Similar result in non clinical sample (Jacobsen et al 2000) Clinical implications

27 Consequences of Disorganised Attachment representations

28 MCAST D in clinical and non clinical groups (Green et al 2000, 2004, 2007) total D % school (n=55) clinic 1 (n=49) clinic 2 (n=64)

29 Disorganisation predicts high symptom scores within clinical sample CD/ODD (n=64, Green et al 2007) D (34) non D (27) parental eyberg Chi2 = 6.9 P=0.008

30 Disorganisation and parent rated symptoms clinical referral sample CD/ODD (n=64, Green et al 2007) B CI P Age ADHD diagnosis Maternal depression Child disorganisation Maternal EE

31 Variables predicting teacher rated symptoms B CI P Age ADHD diagnosis Maternal depression Child disorganisation Maternal EE

32 Attachment and social cognition Attachment and social problem solving (Dodge) Zaccagnino and Actis Perinetti (n=64, 4.5-7yrs, non clinical sample) Disorganised Secure Less competent (F= 4.183, p= 0.048), more passive ( F= p= 0.009), and more aggressive (F= 5.211, p= 0.029) More competent strategies to resolve social situations, negotiating with their peers Less calling on an adult to intervene, reacting aggressively, or remaining passive Ambivalent Aggressive reactions Attachment and emotional understanding (Colle, del Giudice,Turin; n=122, 6y 9m-7y 6m) Disorganised marked decrease in mentalistic explanations fewer strategies of cognitive engagement (e.g. reappraisal) Avoidant substantially more interpersonal regulation strategies No effect with respect to discrimination, labeling and correct explanation of emotions

33 Attachment, social functioning and psychopathology

34 Attachment, social functioning and psychopathology (Futh et al 2008) 2 stage recruitment from deprived urban community N=113, 48% male. Mean age 66 months Ethnically diverse Oversampled for disruptive behaviour (teacher SDQ); resulting 50% from the high-risk and 50% from the non-high-risk groups Attachment representation (MCAST) Behaviour (teacher and parent SDQ) Peer nomination (Dodge)

35 Attachment and teacher rated SDQ Conduct Problems Prosocial Impairment B(SE) β B(SE) β B(SE) β Step 1. Constant 4.32 (2.11) 5.02 (2.81) 1.36 (1.01) Maternal educ (.17) (.23) (.08) -.05 Income.03 (.15) (.20) (.07) -.07 Free school meals -.50 (.50) (.67) (.25).03 Gender (boy).83 (.39).20* (.52) (.19).05 Verbal IQ -.04 (.02) -.24*.03 (.03) (.01) -.06 Ethnicity African.40 (.69) (.92) (.33) -.13 Afro-Caribbean -.62 (.70) (.93) (.34) -.08 Other -.61 (.69) (.92) (.33) -.18 R2 =.17* R2 =.19* R2 =.10 Step 2. Engagement.03 (.26) (.35) (.13) -.29** Positive Content -.35 (.33) (.43) (.17).14 Coherence.42 (.33) (.44) (.16).11 Disorganization.75 (.31).37* (.41) -.40** 1.23 (.30) 1.19*** R2 change =.09* R2 change =.10* R2 change =.18*** * p<.05, ** p<.01, *** p<.001

36 Attachment and teacher rated SDQ Conduct Problems Prosocial Impairment B(SE) β B(SE) β B(SE) β Step 1. Constant 4.32 (2.11) 5.02 (2.81) 1.36 (1.01) Maternal educ (.17) (.23) (.08) -.05 Income.03 (.15) (.20) (.07) -.07 Free school meals -.50 (.50) (.67) (.25).03 Gender (boy).83 (.39).20* (.52) (.19).05 Verbal IQ -.04 (.02) -.24*.03 (.03) (.01) -.06 Ethnicity African.40 (.69) (.92) (.33) -.13 Afro-Caribbean -.62 (.70) (.93) (.34) -.08 Other -.61 (.69) (.92) (.33) -.18 R2 =.17* R2 =.19* R2 =.10 Step 2. Engagement.03 (.26) (.35) (.13) -.29** Positive Content -.35 (.33) (.43) (.17).14 Coherence.42 (.33) (.44) (.16).11 Disorganization.75 (.31).37* (.41) -.40** 1.23 (.30) 1.19*** R2 change =.09* R2 change =.10* R2 change =.18*** * p<.05, ** p<.01, *** p<.001

37 Attachment and Peer Sociometrics Liked Disliked Fights Maternal educ Income Free school meals Gender (boy) *** Verbal IQ.26** -.28** -.09 MC Positive Content Coherence * -.16 Disorganization Regression analysis: Coherence/Disorganisation.09.21* showed shared.15 variance neither result independent of VIQ N s range from ; * p<.05, ** p<.01, *** p<.001.

38 Attachment and Peer Sociometrics Liked Disliked Fights Maternal educ Income Free school meals Gender (boy) *** Verbal IQ.26** -.28** -.09 MCAST Engagement Positive Content Coherence * -.16 Disorganization.09.21*.15 N s range from ; * p<.05, ** p<.01, *** p<.001.

39 Attachment to mother at age 5 and sociometric status at age 9 (Verschueren et al Ch Dev 2001) secure avoidant 10% 27% 47% 45% 27% 45% bizarre/ambivalent 17% 58% 25% naverage npopular nrejected

40 Attachment disorders on Axis 1 Disorders of non-/highly disturbed attachment Disinhibited attachment disorder Relates to studies of institutionalisation Inhibited/reactive attachment disorder Relates to studies of maltreatment

41 Disinhibited attachment Disorder Diffuse attachments during first 5 years of life. Lack of: normal tendency to seek comfort from others when distressed; selectivity in the people from whom comfort is sought. Social interactions with unfamiliar people are poorly modulated. At least one of the following must be present: generally clinging behaviour in infancy attention-seeking and indiscriminately friendly behaviour in early or middle childhood Lack of situation-specificity in the above must be clear. Diagnosis requires that the symptoms in the first two criteria above are manifest across the range of social contacts experienced by the child

42 Inhibited ( reactive ) attachment disorder Onset before 5 years Strongly contradictory or ambivalent social responses that extend across social situations (but may show variability from relationship to relationship) Lack of emotional responsiveness, withdrawal reactions, aggressive responses to the child s own or other s distress, and/or fearful hypervigilance Some capacity for social reciprocity and responsiveness is evident in interactions with normal adults The criteria for pervasive developmental disorders are not met

43 Comparison of described behaviours in attachment disorders and attachment disorganisation Disinhibited attachment disorder Reactive attachment disorder Sequelae of disorganised attachment Mental state/cognit ion Attentional difficulties * Cognitive and communication delays+ Poor social perception+ Bizarre fantasy Poor self esteem Disorganised cognitions Poor social perception/mentalising Behaviour Non selective attachments** Superficially and indiscriminantly friendly** Poor peer interactions** Quasi autistic social impairment* Contractictory ambivalent responses** Emotional disturbance** Hypervigilance and arousal** Aggressiveness** Social impairments** Contractictory ambivalent responses Emotional disturbance Hyper vigilance and arousal Aggressiveness Controlling interactions with others * O Connor et al (1999), + Richters and Volkmar (1994), **Features from ICD10

44 Percentage of sample Attachment Disorder (CAPA-RAD) and Attachment Representation (MCAST) (Minnis et al 2009) RR for RAD/controls on insecurity 2.4 ( ) Cases (n=28) Controls (n=35) Secure Insecure Avoidant Insecure Ambivalent Disorganised Attachment patterns All varieties of attachment category represented in RAD (cf also Chisolm et al 1995, O Connor et al 2003, Zeanah et al 2005) RAD behaves more like a pervasive social impairment syndrome (Green 2003)

45 What does this tell us? Attachment disorder may be a misnomer Early social deprivation absence of opportunity for establishment of reciprocal attachment relationships may lead to significant, pervasive and enduring social impairment

46 A spectrum approach adapted from Boris and Zeanah Secure attachment (Organised) insecure attachment avoidant, ambivalent Disorganised attachment Attachment disorders Social skill in mentalising and competent responding Less competent/more aggressive responding Mentalising deficit. Lack of response strategies Pervasive mentalising deficit and passive response strategies Link to quasi-autism in institutionalised samples

47 Treatment approaches

48 Case management and alliance Bowlby s model of therapist as secure base Core non specific aspects of engagement illuminated by attachment theory Evidence for effect of alliance in treatment outcome (Green 2006) Martin 2000 metaanalysis - relationship with outcome r=.2 Patient led, focus on core disclosures Therapist sensitivity in responding to these ( accurate empathy ) and reflective function Distinction from transference By analogy with differential sensitivity findings in relation to parenting the most vulnerable patient groups differentially sensitive to therapist effect?

49 The focus of attachment specific treatment Personality Mental State CAREGIVER Attachment Representation Social Stress and Support Parental state of mind and behaviour CAREGIVER- CHILD INTERACTION Child state of mind and behaviour CHILD Attachment Representation Social Circumstances Developmental Factors Mental State

50 Less is more targeting parental sensitivity in infancy and preschool Bakermans-Kranenburg et al 2003, inclusive metaanalysis of 81 studies (n=7636), 51 RCT (n=6282) Overall effect on sensitivity (d=.33, p=<.001) Brief focussed personalised video aided interventions with parents most effective (<5 sessions, d=.42, >16 sessions, d=.21) beginning after 6 months rather than earlier (>6 months, d=.44; <6months d=.28) Overall impact on child attachment smaller (d=.2, p<.05 in 23 RCTs) Studies with greatest effect on sensitivity showed greatest effect on attachment More dynamic, less focussed, psychosocial interventions less effective Little longer term FU Juffer et al (2005) focussed intervention in high risk sample suggested positive impact on lowering disorganisation

51 2 nd prevention in high risk infants Van den Boom (1994/5), RCT of brief intervention at 6-9 months vs TAU for temperamentally difficult infants (n=100) Brief sensitivity focussed intervention for mothers (3 sessions) Relative increase in secure attachment at 12 months in intervention group (p<.001) Effect maintained at 3 ½ yrs; children in intervention group more secure (p<.05) Benoit et al (2001), video aided brief intervention reduced atypical maternal responses, controlled study against feeding intervention

52 Altering Attachment Representations Personality Mental State CAREGIVER Attachment Representation Social Stress and Support Parental state of mind and behaviour CAREGIVER- CHILD INTERACTION Child state of mind and behaviour CHILD Attachment Representation Social Circumstances Developmental Factors Mental State

53 Attachment representation Circle of security (Marvin et al 2002) Adapts therapeutic approach to parental attachment dynamic How parental experiences sensitises them to particular child approaches Toth et al (2002) comparison of parent psychotherapy, psychoeducation, TAU in maltreated children risk families PPP group showed greater treatment effect than other interventions (p<.001) Green et al (submitted) cohort study of effect of WS parent intervention on MCAST representations. Children with externalising disorder, (n=63)

54 The effect of parent training on attachment representation Pre-intervention Post-intervention Increase in security (t=2.09; p=0.04) Security scale Attachment disorganisation Coherence Maternal warmth/sensitivity Assuagement of distress narrative coherence (t=2.88; p=0.005) maternal warmth/sensitivity (t=3.29; p=0.002), Decrease in attachment disorganisation (t=2.66; p=0.01).

55 Interventions with older children Parent child game On line social sensitivity Working at the level of attachment representations CBT or play therapy

56 Summary Attachment theory provides a useful approach to modelling non specific factors of engagement and alliance Case management can include parallel complimentary approaches to intervention The evidence supports focussed video aided work on caregiver sensitivity rather than traditional parent psychotherapy approaches Context related sensitivity may be particularly important Video feedback allows attention focus Reflective functioning on impact of child on parent Preliminary evidence that interventions can impact on attachment representations on older children

57 Thank you!