Professor Stephen Scott Hi, my name's Stephen Scott. I'm a Professor of Child Health and Behaviour at the Institute of Psychiatry, Psychology and Neuroscience at King's College London, and I'm a Consultant Child and Adolescent Psychiatrist at the Maudsley Hospital. Today, I want to talk about Attachment After Infancy, and ask whether that concept still is important, or whether it's all over once you are outside the early period of, say, nought to three or four and start going to nursery school and meeting other people. A lot of people have helped me in this research project I'm going to tell you about, and they are named there, and we've had a number of grants. close together, and, particularly, at the minute, we're talking about whether the child attaches to the parent rather than the parent bonds to the child, is an important one. And this is an advert for a very expensive Swiss watch, which costs about 10,000, you ll notice it on the guy s the father s wrist on the left, and it s, sort of, this thing, oh, it s you're, you know, buying an expensive watch, not because you're an egoist who wants to shop, you re giving it to the next generation. So, attachment is a good selling tool, as well as important in child psychology. So, I now want to distinguish between attachment disorders and attachment patterns. Attachment disorder is quite serious, and it means you 've failed to develop the comfort-seeking of attachment when things are not going well, and it should be to a specific caregiver. There are two types reactive attachment disorder, this is where they're very, very frightened and cowering away and look very, very anxious, and won't seek comfort under a stressful situation. The other used to be called disinhibited attachment disorder, it is now rephrased as disinhibited social engagement disorder, pretty much the same thing, that you can just go up to anybody in the street and get overly close in an inappropriate way. Both of these are associated with pretty bad deplication deprivation or neglect, and often lots of changes in caregivers in early life, not so much frank abuse. And it needs to be distinguished from the effects of trauma or abuse, it shouldn't be explained by developmental disorders, such as autism, and it should be evident, before the age of five years, when the attachment system is most salient. And, after all, hanging on to your parent is going to be give you good survival value out in the wild or, indeed, in a busy supermarket. Now, how prevalent are these attachment disorders? Pretty rare really, and one paediatric clinic sees zero in 300 cases. In the impoverished Head Start Program, zero in 24, two out of 25 in homeless children, both of those were disinhibited social engagement disorder, and about up to 10% in a maltreatment clinic. The National Looked After Children Survey, so these are people who have been subjective to severe abuse or neglect to mean them to be taken into care, which is only 5% of the population, in that it was only 2%. So, pretty rare as a disorder, and in our own clinic, a lot will refer with this idea that you ve got an attachment disorder, but actually only about 4% got diagnosed using the correct criteria. But what is missed often and called attachment disorder is conduct disorders, oppositional desi defiant disorders, more than 50%, about a third have got ADHD, about a 15%, have got autism-like things, and 10% have got a generalised learning disability. So, as a Clinician, I want to warn you not to attribute everything to attachment, it can be an umbrella term. Just cause somebody had a difficult upbringing, that may not be the problem. Now I want to talk about attachment patterns. These were enunciated by John Bowlby, and different parenting styles have been strongly associated in several studies with different patterns. Dismissive parents, Don't be silly, just pulling away, lead to an avoidance and, sort of, little public schoolboys who get sent away to public school age seven have to be really much independent and work it out for themselves. They can look indifferent, but actually, under stressful situations, or if they re with their father or mother, actually, their pulse rates go zooming up, so it's not true that they really don't care. Inconsistent parenting, where you do one thing one day and not the next, can lead to ambivalent, preoccupied attachment, and the one that's most concerning is that abusive parenting can lead to this very disorganised pattern. There's an association with aggression, because frustration, irritation, cause you don't get comforted and don't have self-comforting emotions and skills, and you don't learn emotion regulation. They may need to try and control the parent cause they're frightened of what's coming next. And when it's abusive, it can overwhelm any, kind of, coherent response. So, we've all got an attachment pattern as opposed to an attachment disorder. John Bowlby is the father of this, at the Tavistock Centre, in three seminal works. Mainly about babies and young children, and the parenting style he described, which has been supported by future research, is sensitive responding. Then, if you get that, the infant is then secure to explore the world. Over time, the infant builds up an image in their head, an internal working model, of the parent as somebody who can look after them, and that helps them get resilience and be not go off on one when things don't go their way, builds emotional regulation. In infancy, it's measured by the strange situation where there s an ex mother of the child, experimenter comes in, usually mother, the mother or a parent withdraws, and the child gets distressed and you look at what happens on reunification, does the child go to the parent and go, Oh, that s better ? Or do they look indifferent in an avoidant pattern? Or do they thump the parent in some sort of ambivalent, they won't let go, they're preoccupied with their relationship. Or are they all over the place, diving under the table in some disorganised pattern? Later on, and more recently, we have methods of using representational doll play tasks, which I'll show you in a minute, and the Adult Attachment Interview, which is now being used with adolescents as the Child Attachment Interview. So, we talked about sensitive responding, is that all you need to have? Does it matter how we measure good parenting, what is best for child outcomes? Is it just good, and however you measure it? Or does it matter how you conceive and what you watch out for when you see parents and children? I want to discuss two outcomes, one is antisocial behaviour and the other is attachment. Both are very related to the peer child rearing environment. So, one outcome is child antisocial behaviour, which traditionally is associated with a behavioural parenting style that you need to reduce it by giving lots of praise and rewards and attending to the child, and setting calm limits. And then child attachment security is traditionally associated with attachment parenting style, which is sensitive responding. And the question is, how do these two link up, both the parenting styles and the child outcome? The trouble with sensitive responding, It doesn't describe attachment theory of parenting and doesn't mention setting of limits and boundaries, and their relation to non-compliance. Doesn't talk about the impact of rewards, sanctions and skills modelling on the effect of that on the child, and it doesn't mention other environmental influences, such as meeting peers, educational difficulties, and so on. So, what about attachment after infancy then? Does attachment security predict function or do other influences take over? Maybe by the time you get to school what's more important is your peer relationships, or other things can get into play. And is sensitive responding just good parenting, or is it distinct from the social learning theory values of parenting? And then, does sensitive responding have unique predictive power for attachment security or, actually, whatever measure you use of good parenting, is that good enough? These are the questions I'd like to answer with you. So, here is a ta here is I was talking earlier about a representational task, here is an example of our doll play task, and I'd like you to watch this and think about the representation by this girl of attachment. Does the mother, in this case, provide comfort to the girl? And does she feel resolved after the episode? What happens is the experimenter is going to not just talk about a situation, she's going to add in some emotions and say, Oh, oh, what's frightening? So, I'd like you to watch this please. [Video commences] Parent It's those handles, If you'd like to take it and go back to bed, okay, and that's it. I m going to tell the next story now, so are you listening? Child Yes. s the middle of the night and it s very, very dark and very, very quiet, you can just hear some breathing going on [pause]. It s very quiet. All of a sudden, Hannah doll wakes up. Ah, oh, oh, she says, I've had a horrible dream. Oh, it was a horrible dream. Ooh, what a horrible dream. Show me what happens next. Child Then she wakes up, she s walking, says, Mummy, I had a horrible dream, and she wakes up and they went downstairs and they're sitting down [pause]. And then they're speaking, and they say, I had a horrible dream, mummy, so they get off the chair and then they went back to bed [pause]. Then they went back to sleep, then it's morning. She looks at herself and gets ready and then she went downstairs, watching some TV. And then her mummy wakes up and she's going to have a bath. Then she gets out of the bath, got ready, and she was watching TV as well. Parent What is Hannah doll feeling now? Child She's feeling happy. Thinking about happy stuff, not about the dream anymore. Parent Not about the dream anymore. What about Mummy Doll? What is she feeling? what's she thinking? Child She's thinking, how does she get this bad dream? Parent Alright. [Video ends] Professor Stephen Scott So, first of all, we'd ask ourselves, is this organised? Can you follow the thread, or is it disorganised? I would say this is a very clear narrative, with a beginning, a middle and an end. Does she get comfort and assuagement from her mother figure? Yes, she does. So all of those are good, and, interestingly, when asked about the mother's feeling, she construes the mother as being concerned about her, her daughter, that she's worried about how her mother got on. So we would call that a secure attachment pattern. Now let s look at this lad. [Video commences] own and he s playing, what would he play if he's out on his own? Child Squash. Parent Squash? He plays squash, does he, with a ball and a racket? Child Do you know how you do squash? Parent No, you tell me. Child He's got to kick it against a wall and then when it come back he's got to kick it again. Parent Oh, kick a ball against the wall. Okay, so Ricky doll is playing squash, he's kicking the ball against the wall and it's coming back to him and he s kicking it and he's kicking it. He's doing very well, cause the ball never gets past him. He's kicking it with his left foot and his right foot and his left foot and his right foot. He s getting faster and faster and he the ball runs off, so he has to run after it. Then, Ow, ooh, he falls over and he's banged his knee, Ow, ooh, he says, my knee hurts. Child He's broken this. Parent My knee hurts. Ooh, it's bleeding. Show me what happens next? Child What's the matter? This, ooh, he s got to go upstairs. He's stuck now [pause]. He's gone back to sleep. The, he's he put the thing outside to try to trap himself, then he puts the TV there, and so he puts the TV there, and watched TV outside, and then mummy suddenly she hears a bad noise, and then, this is starting to wobble. Argh, and then she drops right down. Then he s tried to get this out, then get this, and throw it at the ghost. Then comes on the roof, gets the train, and don t let them sleep on the bed [pause]. Go to bed and then he's dead, cause there s a ghost there, and he never thought there was a ghost in his house. And then, this started. What's that? Parent You remember you were completing a story, Ricky? darling. Child Where are you? Oh, wait, let me see me. Why am I in red? [Video ends] Professor Stephen Scott So, I think you ll see this an engaging boy, but the story wasn't very coherent, and it ends up with his mother falling off and dying, and he would get a disorganised categorisation, cause it wasn't a coherent story and he didn't get much comfort from his mother. So, then the question is, are these just stories? So, what do they relate to real world adjustment? And so we did that with 113 children, aged four to six, and those who had secure attachment, both parent and Teacher rated better functioning. Disorganisation particularly predicted conduct problems, less sociable behaviour and more general functional impairment. So, from that, we concluded that attachment in childhood, so that's beyond infancy, does predict adjustment. So, we might all want to think, what should we be looking out for when we see parents and children together? You might not see attachment behaviour, you might see parenting behaviour in your clinic or wherever. So, let's then look at the parenting style of these two children. Here is the girl who was securely attached. So what we're looking for here is sensitive responding, but do they have a conversation together? Do they have fun? Do they pick up each other s ideas? Do they build something that leads to mutuality between them? [Video commences] Parent Okay, maybe I ll make a chicken, I like chicken. Do you like I like chickens. Child And ducks, quack, quack. But I don't like either. Parent, Huh? Child I like ducks, but I don't eat. Parent Oh, look at that. Oh, remember we had that, you put the dough in until you squeeze it Child Oh yeah. Parent and it comes out at the back. Child Is it this one? Parent Let me see. Yeah, that's the one [pause]. Okay. Child Yes. Parent Ooh, look at that. [Video ends] Professor Stephen Scott So, I would say there was some fun getting on there, they're having a conversation about the ducks and quite quietly relating it to their own experience. So, we would rate this reasonably high, on a seven-point rating scale, maybe five or even six for sensitive responding. Let s now look at the lad who had a disorganised attachment style and how he got on in our little experimental task with his parent. [Video commences] Parent And stop the other side. You've got to do the same thing as you done to that [pause]. Right. What's next? Child White. On the lines? Parent Hmmm hmm [pause]. Right, how many you got to do [pause]? Child Seven. Parent Alright. Child Seven, eight. [Video ends] Professor Stephen Scott So, this isn't awful, but it s rather minimalist and not particularly warm, not much communication coming from the mother here, or encouragement, or to and fro. So, we would give them a score of maybe three, or perhaps four, out of seven, probably three, for sensitive responding. So, does it matter? Does it work in our experiments? Well, yes, it did, more sensitive responding was did predict attachment security, over and above the more behavioural way, how many praises and rewards they gave their child. so you it isn't just one style of parenting is good, the sensitive responding was specific for attachment security. And vice versa, when you measure criticism, making critical comments at them, with some emotion, that predicted difficult behaviour over and above the sensitive responding lag. So both seem to be important, the attachment theory and social learning theory measures of parenting. So, I would argue that we should have both of these in mind when we see parents and children together, and it's often informative to get them to do a little task rather than just interviewing them. is it related to adolescent adjustment? And is it just a read-out? If it is, if secure is it just, well, that's how they're being parented at the minute, or does the early parenting matter? Do you carry around inside yourself an internal working model of what your parents were like? And what kind of parenting predicts security now? developed from the Adult Attachment Interview by colleagues at the Tavistock Centre, Peter Fonagy and Co. You ask three questions about the parent, ask them to give specific examples and not just be over idealised, and you score them for coherence, balance and detail. And here, because I worked in an adoption and fostering clinic, we did both birth and foster parents. So, here is example of the Child Attachment Interview. [Video commences] Interviewer And can you tell me three words to describe your relationship with Trish? So, what's it like to be with Trish? Child Well, she s caring. Interviewer Yeah. Child She isn t soft, a pushover. Interviewer Okay, and one more? Child She is unhappy that she's my mum, cause Interviewer Okay, so the first one you said was caring, and can you tell me about a time when you felt that she was caring? Child Well, it was a last year. I was being sick all over the night and she came and sat in my room next to me and didn't leave me. Interviewer Okay, and how did it feel when that happened? Child Happy. Interviewer Yeah, how do you think Trish felt? Child Tired. Interviewer Tired, okay, and the second one you said is that she isn't a pushover, can you tell me an example of her not being or when she when you felt that she wasn't being a pushover? Child Cause she usually lets me watch the football, if she's not, she might not let me tonight. Interviewer Right, okay. Can you think of the last time she wasn t a pushover or when you felt that she wasn't a pushover? being silly at school? Interviewer What were you doing? Child I was just I was saying stuff, like, My name's Jim Bob. Interviewer Oh, right, and then what happened? Child Nothing, and I just got told off and then my got sent back to class. Interviewer Okay, then what did Trish do? Child Took my PlayStation away. when that happened, or ? Child Upset.