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    Lieberman 1995

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    INFANT PSYCHIATRY 1055-1993/95 $0.00 + 20 DISORDERS OF ATTACHMENT IN INFANCY Alicia F. Lieberman, PhD, and Charles H. Zeanah, MD ‘The infant-mother relationship has ong been recognized as pivotal a shap- ing personality development. Two muuch-qooted statments represent the vi Winhicot’s terse quip that “there ino suc ng as a baby™ (eating that babes ean be understood only inthe context ofthe mothering they reve), and Fred's unsurpassingly impassioned insight that te chld-mather aatonship “unique, without parallel laid. down unalteably for'a whole iene, a¢ he fist and stronger ove object and as the prototype ofl later love relations for both sexes" “Given this emotional pre-eminence, is not surprising thatthe inn mother relationship has the power to promote mental health or serve a6 the feness of peychopathology in te young child. ‘Disorders of atachment i infancy’ ean be define! most sucinctiy as devi tions fom the normative patterns of Flatonship Between a child under 9 year of age and hs or her primary mother figure. Although seemingly straightor- ‘ward this dofintion conceals several sues of possible controvery. For exarn- ple, how do we define a mather figure? Is there only one mother figure ins Enis Tie oF can a father oe beloved Fulltime caregiver quality for Ths rol? What is-2 “normative pater of attachment” and how do we incorporate individual diferences,citual mores, and chidrering values into our under Slondng of what is normative? If mental heath is powerullyinfuenced by he ality 6 the child's relationships can there be nomorgenc mental heath disor cles in infancy that do not involve disorders of attachment at least fn some wy hexaploid wo th ee tine suffering hom an attachment disorder? In otber words can we ver astess fn infant's poyehological functioning independently ofthe quality of pemary Care she ot be fe reclving? ‘These questions represent staring points to challenge our thinking and to be dlalogue and debate. There tic as yet no Gefiniive answers. Althoogh From the Infant Parent Program, Department of Psychiatry, University of California San Francs, San Francia, California (AFL, and the Department of Psych, Lous! na State University School af Medicine, New Orleans, Louisiana (CHZ) (CHILD AND ADOLESCENT PSYCHIATRIC CLINICS OF NORTH AMERICA ‘VOLUME 4 NUMBER 9 -TULY 195 sm ‘572 _LIRERMAN & ZEANAH we have Ieamed much about mental health and its disorders in infancy, a Consensus about etiology, assessment, and diagnostic ites is sll in the process ff evolving. This article ix designed to (I) explicate briey the concept of attachment and its behavioral and representational manifestations, (2) desceibe formative variations in the quality of attachment in nonclinical populations, (3) Clucidate when relationship disturbances become disorders of attachment, (8) propose a nosology for these disorders, and (5) desceibe infant-parent psycho therapy as the most comprehensive method currently available for treating disorders of attachment. WHAT IS ATTACHMENT? ae a a Sr vege be el ene 2 os ea ese ates catia a ea a as a feeling of security about the attachment figure's physical and emotional sean Pain infancy, attachment is manifested behavioealy through patterns of behav. ser spare ana Pea eat Seether es gee eae a dl ah ao a sone mempatents pies wih eral Scien Se ere eae oie teenie eee sa ee elena cee arb ena, erat ees cel me pre sr Be Sa ae are tia ree a el eee Fg kp oetlelpi ipod ny eye er sere DISORDERS OF ATTACHMENT IN INFANCY 573 attention I want?” The infant's inner experience of need and behavioral expres ‘sion pose the question; the attachment figure’s response and the infant's percep. tion Of that response provide the answer. This answer in tur affects the next {question asked by influencing the infant's affective state and repertoire of avail able signals. The infants and mother’s reciprocal attunement and the affective ‘domains in which attunement or misattunement prevail affect the emotional {Quality ofthe infant's attachment tothe mather "=" Quatity of attachment ‘An attachment can be secute oF anxious, a qualitative feature inherent in the definition of attachment as an intense affective bond centered on the issue ff safely and protection? Secure infants have a reliable expectation that the attachment figae wil be consistently avalable and cesponsive tthe ipa particularly those Involving distress and the need for protection and rele ‘Anxiously attached infants, in contrast, anticipate that thelr attachment figure ‘wll be at best erratically available and’ will not provide a consistent feeling of belng protected from exteenal danger or intemal heed “The most widely used research method for assessing the quality of attach- ment was developed by Ainsworth ot al? This cassifieaton system is based on 2 20-minute laboratory procedure (the “strange situation”). The infants response to the reunion with the mother after two brief separations provides the basis for the tachment lor, wich invelies the major etegres desribd ‘Secure infants (group B) want proximity, contact, or interaction with the mother and seek it out actively. They may or may not be distressed by the Separation from the mother but ae clearly glad to see her when she comes back; they greet her with a smile, a gesture, a voralization, a cry, oF an approach behavior. They are cleariy more intrested in contact withthe mother than with the stranger and, if distressed, they are more readily comforted by her. There is little tendency’ to resistor avord contact and interaction with the mother. On the contrary, secure babies are likely fo maintain proximity and contact, particularly a el a ce “Avoidant infants (group A) show a matked avoidance of proximity and interaction wih the mother in the reunion episodes. Tey look away, turn aray, move past the mother, oF ignore the mother’s return. In some instances, these ‘behaviors predominate: in others, avoidant behaviors are intermingled with a casual greeting or other interactive behaviors, In any case, avoidant babies tend to treat the mother much as they leat the stanger. They may actually be less avoidant of the stranger ard are readily consoled by the stranger when distressed ‘Resistant infants (group C) show conspicuous resistance ta contact or interac- ‘ion with the mother, particularly on reunion. They may initially seek proximity ‘or contact, only to promptly eect it by pushing away of squirming to get own, giving an impeession of ambivalence: Anger toward both the mother and the sanger pervasive in ths group, sabe! of extant infant passivity is a notable feature: the babies merely protest being put down rather than actively resisting release, and their exploratory behavior lacks a sunse of active initiative ‘Disorganizalftsorientd infants (group 1D) show either no coherent strategy or significant disruptions in their strategies for coping with the cumulative Stresses of the strange situation, most particularly the challenge of separation 574 LIEBERMAN & ZEANAM, and reunion with the mh, Thee behavior seems to lack an observable gal 3: well a a ready explanatory mechanism for is oocurence:By definition, tN isa behaviorally hettrogenechs group. Behaviors indicative of Uiorganizabon, thowever, involve Ihese major Hoes: sequential oc simulans splays of contradictory behavior paters; unditecte, misdirected, ot inferrmpledove- iments and expression; serwotypicur anomalous postures freeing sling, and slowed movements and express; dissct indiser of apprehension about te parent and behaviors indicating confuson” Hierarchy of Attachment a fa ee Br te i ee a ae nese a ne a Bae ecco seer ee arc ata tn pe rasa ale ae ca Py pobiap ee tempyo ted pirate gan ta seen mee DISORDERS OF ATTACHMENT ‘The quotative variations in normative patterns af attachment described by Ainsworth et aF and. Main and Solomon® have received extensive empl ‘aldation dough their use in hundreds of research studies. Although ex Incmely sell in guiding dbvervation an researeh its mportant to remember that these categonts originated from studies of nonclinical samples. In sditon, these categories are based on infant behavior Ins single laboratory situation that cannek provide the variety of information needed for diagnose purposes ‘The rencarch-based lacifiction of ltachment docs not constitute 3 sat of lngnostic categories. An infant categorized as anniously atached inthe strange Shation oes not necessary suffer from an attachment disorder ” To ele ‘late when a partici fective of behwviorl organization qualifies as a disor Ser, we rut determine whether i interferes wit other areas of adaptation and wether is intensity and persistence are beyond age-appropriate norma B these standards nfanis caste! a ansous nthe strange iteation would ned to be asnened further in'a variety of contests (home, chidare sling. play- DDSORDERS OF ATTACHMENTIN INFANCY 575 round) in onder to determine whether the defensive patterns of avoidance, Eiistnce, or disorganization Rave the scope and rig chamctenstc of ds one in assessing an attachment disrder, iis also important to remember that infants are capable ofa varely of detenses that arent necessary apparent in any one singe evaluation, Aggression, transformation of aff inhibion, and irceing ae cme examples of mechanisms used by Infants o ward of pif MiecSe = Unfortunately, the clinical knovelalge negarting disoriern of Sttachment in infants as not yet been syateratized inthe frm of empiically ised entries validated by esearch The moct widely sed categories fr attachment disorders are those dee scribed inthe Diagnostic and Sitatial Manal of Mental Dsorders (OSM nd USMLAV) a in the International Clasiaton of Diseases (ICDA) In foth daaalcatons the main cntron is eeveru and pervasive iturance of Socal relates aoa soca situations. These datrbnces may’ be manifested through feo types of soca interaction: hypevigslan responses towards one oF tnove adler indiscriminate soda, where the child does no diferente fetween adults but eater seeks proximity and conte th anyone who might Sermomentaiy avaible "fhesecesptons are useful in identifying the emotional disorder that rest when ocd fs not given the opportunity to become attached. They hot address, however, the problem of 8 ocuzed athment relationship of @ Strongly pathologie naire ier problems involve the focus on aberrant socal behavior rather than altachnent te fare to integrate findings from developmental atachment fescarch athe emphasis en tatreatmentsyeiemes reer than on dsr ‘ances of atachment In nd, there have been no tis of thereby fr validity of the criteria for diognening attachment disorders in the DSM oF 1D apse, Rinore recent approach to describing disorders of attachment is used in the Diagnostic Clastiation Manual of Zoro to Thee” National Center for lineal vant Programs" This manual inconporates the tational deiiton of Reacive Atachmart Disorder, butt goes further in ncaing section on te Classification of relationships according to their quality and type and degree of pavshopathology 7 Reslogy of attachinent disorders more consonant with current rewarch on atachonert and encompassing + greter range of stacent disorders ws proposed by Zennah, Mammen, sn Uberman® The version presente here En Ocencion of that ore “Attachment disorders ay be divided into the major categorie: dlsorders of nonatachmen, disordered attachments, and disorders of alse (st oF Sroken) attachment. Each ofthese cateorcn s deserted blow Disorders of Nonattachment Infants with a disorder of nonattachment do not demonstrate a reliable preference for an adult caregiver. They do not turn consistently to a specific person for help when sick, hurl, hungry, or in other situations that ordinarily tlicit attachment behavior. The preslominant alfect may range from emotional ‘withdrawal to indiscriminate sociability. Two categories of disorders of nonat tachment can be distinguished on this basis typeI, involving emotional sith- drawal, and type I, involving indisriminate sociability or "social promiscully.” 576 LIRBERMAN & ZEANAHL In type |, disorder of nonattachment with emotional withdrawal, the child ‘manifests constriction of affect and litle evidence of spontaneous pleasure either {in socal interaction or in exploration ofthe inanimate environment In type I dlsordee of nonattachment with indiscriminate sociability, the child evidences 3 shallow affect, inchuding overly bright smiles, phony laughter, and superficial expressions of affection, Separation protest is either absent or expressed in ‘elation to many people, including strangers Disorders of nonattachment have been described in classic studies by Provence and Lipton. Skeels™ Tizard and Rees" and Tizard and Hodges i has Tong, been assumed that this patie is characteristic of chilren raised if instittions, and in fact the vivid descriptions of msbitutionalized ehidren in the studies cited above were instrumental in the shift from institutional care te individual foster homes for children removed fram their biologie families, As the cases below illusizate, however, frequent moves and mediocre foster care ean combine to produce disorders of nonaltachment even among children receiving ostensibly individual care, ‘Case Example—Type I: Disorder of Nonaitachment With Emotional Withdrawal Regge was referred at 22 monthe of age fot evaluation because of fae to thee ad complinis by hs foskt mother that he Rad no intreat ifod Sra that he didnot ike to py wit oye oe poop. Meal exams showed ne Sane resson forte fare to ve ou the ci’ Fistor incest at a BRK Rope hada postve toxicology seen for cack eocin, wat small fr stator age, and had incr bleeding. He was discharged from the Sebornnurtey ot 2 weeks but a enced wine week wi pretnona Fis parents failed to Voit or to pick him up when he wos lgcurged, At one ‘ronlh, Koggie war placed in 4 temporary shelter home pending efor a ‘eurication: When Ris penis could not be located, Regge was placed in ¢ feter Rome at 2 month of age Por uncles tensors, Rees andere 1 + deren foster home month ater, when he was 8 months old, nd was ng inthat home a he tine o eet Tnntrecton with is fster mother Regie looked apathetic and unreapr sive, When she showed im tay, Reggie med away fc he, aking er wile vacant expression and fuking no efor eich Out To the tof oF fo ngage In play wit her, He mo speak or sine The foster mothers ale Felted ef t engage him were mel oy Regs’ tent sae Tes deseanor {id mot change in Ne Surat ots 2 nue pS session with te str moter eggs Coevior was cletonialy ident when he es slone Wilh asses Alhouh he ws nally ll een ard hep i dsc frm er Jc evenly responded to he assem lw kay eat to engage bi tn Bescon He hall ds reiver of be ey leprae we Intel seoreey 2 the aur spoke to him fen another hy pene: Mont tlingly he agent Jo be “fed” Goin a cup aed Boca Incresley ative In's prose Foals Situation even puting # spoon w the asena's mouth when she ead ait we hong Tn api ofthis grit operas ith the sseicr, Regake’ peo mance in the Bayley Scales of Infant Development placed hint at 8 S-month Ital approximally6 mont bow Ns chronologic ape Conversation wih Regge’ feet mother revealed s depressed rblver woman whowe atitude fowds her work was colored by the caer lt of Sother foster child she had planned Yo adopt due tothe e's unifetion DISORDERS OF ATTACHMENT IN INFANCY 577 with the biologic parents, The foster mother cardidly admitted that since this lows she had become inpersonal towards the chilren in her cae, atending thelr physical needs but reusing to become emotionally Invesied in tem, Reggit was clearly suffering from his caregivers emotions! withdrawal, which fee him no opportunity toro an atackment to her. {Acta the nace Regge ma plied nati a with parents who were extraordinarily warm, gregarious, a stimulating, Win fo months af this placement, Reggie gained 1 pound grew 1 Inch and lie proved significantly in he performance on the Bayley Scales, He began tose ‘ords, acquired a pleasant facial expression, and sriled ofen. He spontane- ‘usly approached the adoptive parents to show them toys and lend against them affsctonately. Tis dramatic improvement ruled ott Mental Retardation nd Autisde Spectrum Disorder, two other diagneste categories that had been ‘onsdered prior othe ssessment ‘Case Example—Type Indiseriminate Soctabllity 1a tla Sen ap eal ed ape Beg rete tek a neN epacerg een pare it art ane came inert em ea feed al eo ae oto Sal Sls he eal ar rea eee Seti a Sa eather ce Swe ca eh enna ey SE, paginas ekep ee ete eo ope ay he ed al Si om ee ire oa eae ry ree cs oan Sta pings are a areata cate eete octal gel ney mame ere ee oe te oe a ea ile cates ng he er ge rn ee Maa oe eee ee eee eae Ee eh nh eo a ot ee i ha ee io apn \sorder of Nonattachmont With 578 LIBMDRMAN 4 ZEANAM father, greeted the occupants cheerfully, and resisted going into the playroom ‘with her parents and the assessor. At the end of the setsion, Lois again darted ff to the different offices, complained when she was retrieved, and cried when ‘he and her parents lft at the endl of th sossion. We hypothesized that Lois had developed an indiscriminate pattem of sociability as an adaptation to the many unpredictable changes she Rad had to endure. Although psychologically costly this adaptation seemed the best aval ble response to the citcurnstances in which sho was raised. Lois had no way of Knowing that her new parents would offer her a permanent home. In fact, Anticipating their eventual loss by not Becoming attached (0 them Was the most fiting response fo the internal working model she had developed of caregivers appearing and disappearing at unpredictable intervals and for no clear reasons, ts response, while minimizing pain and anxiety, prevented Lois from learning {o-engage in inkimote interpersonal relationships. "Ta give Lois an emerging certainty that she would ot lose them. the parents were advised give clear messages to the child that they were there te Stay. They were asked to speak to Lois about her previous caregiver in order te help her develop a sense that people continued to exist even after they were gote. They also were asked to tell Los that they loved her and that they would never leave her. This formula was repeated in many versions and in cifferent ircamstances, most particularly when Lois was retrieved from following. & Stranger, during separations, and when saying good-night ‘Within a month of this treatment, Lois began to show her fist separatior protests, which within afew weeks escalated to become a rather intense separa: thon aniety. She kept tabs on Tier adaptive mother and to a lesser extent of het father, cried when they went out without her, and used “where are you?” as + imantra-like question to assure herself that she had not been abandoned. The Separation anbiety subsided after ¢ months of patient and repeated reassurances that hor new parents loved her and would never leave her or let xo of her Disordered Attachments Disordered attachments involve a clear preference on the chik’s part (or the attachment figure, a preference that unlike normative atachments i charac terized by Intense and pervasive conflict due to feolings of anger, fear, anxiety Of other negative emotions, These emotions are not necessarily expressed di rectly but may be masked by defenses such as avoidance, transformation oF affect, fighting, inhibition, and precocious competence in solf care. '2 53" When infants become capable of autonomous locomotion after about 10 months, disordered atlachments tend to be manifested in distortions of sccure base behavior. These distortions involve pronounced and persistent alterations inthe balance between attachment and exploratory behaviors. Thece alterations ‘are prompted by the child's Fear ofthe mother or uncertainty about her availabil ity as a protector" Three categories of disordered attachment are described hep atchmen disorders with bon, ih eeFendangerment and with role reversal Disordered Attachment With Inibtion ‘This diagnostic category i6 distinguished from a disorder of nonattachment by the childs clear recognition and preference for the attachment figure, Att tment behavior is either exaggerated in it expressions (as ina tendency to seek DISORDERS OF ATTACHMENT IN HNRANCY 579 proximity and maintain contact for inordinately long periods of time even in Settings that encourage exploration) oF marked by pronounced avoidance of the ‘attachment figure and hypervigilance. "The hallmark of this syndrome is that the inhibition involves @ marked ‘curtailment of exploration not only in stressful or unfamiliar situations, where Such a curtailment is normatively expected, but also in familiar or enticingly novel circumstances. The child dovs not approach, touch, or manipulate objects even after a chance to become familla with them, of does co only in a desultory fashion, Social interaction with unfamiliar persons is absont or at best perfunc- tory. There isa restriction of the affective range across settings, with a predom- nance of sober affect tinged with hypervigilance and foar. Thore is also a delay in the differentiation of discrete affect, with a relative scarcity of the intense femotional reactions ranging from delight to rage that are 60 characteristic of this age. ‘Gave Example Dahlia, 30 months old, was referred for an assessment by her pediatrician because of concems about her withdrawn affect. The child was developing normally in the areas of fine and gross motor development and the mother feported that she used two- and theee-word sentences but spoke very hit, a Feature that according to the mother Dahlia had inherited from her. Dablia’s mother described het as “too passive.” During the three initial home visits, Dahlia dict not leave her mother’s side and ignored the assessor's socal over" tures. The assessor's report fom the frst session reads Dahlia barely made eye contact with me and clutched a stuffed animal close to her chest. Her mother encouraged he to play with ‘some of the loys and seemed irritated when Dahlia did not want to. The mother complained that she had bought Dahlia lots of toys and that she either didnot want to play with them or wrecked them, ‘About 10 minutes into the session, Dahlia sat on her mother’s lap and fell asleep. She slept svth her sted animal for the remainder Of the session. [This was a midimorning home vist, especially timed to observe the child when she was reste] A similar patter of behavior was observed dung a second visit one week lates, well dng a playroom visit to the oc playroom inte td Weck ‘ol esesament ‘vis to Dahl's daycare centr and intrvicws with the teachers sg- gested That this pltem cf inhibition in exploring the world and excessive Encerm sh proximity to the mother was mie ositatona here the other sere present {in the dayeare cent. Dahlin joined in the sy ates son Sith eer hire se aes engge n goon Phys ay oe lsrig boc Intervitve th the mother revealed that she considered Dahlin to be the rvincamation ef the cds fates who had been murdered while the mother San progr wth Dabs, Th miter had tot tcovered at ber bands Wiolnt death and showed much goief mised with unresived anger Dali's Clinging to the mother and the iaibition of normal exploration md afetive fange fh hor presence can be understod as a rnponse fo the mothers atibuc tone In enance, Daa was complying with the masher wishes to have her take the place of her deceased father rather than leaving the mother’s se a her father di ‘Attachment Disorder With Seitendangerment “Ths subtype encompasses a pattem of reckless, accdent-prone, and agyres- sive behaviors in the context of atachment.Recklessness and acidentproneniess are apparent in the child's consistent fallure to use the mother for sactal montor- ing of cues about danger Pathognomonie behaviors Include daring away fom the mother in untomlior stings epsotdly moving away thot racking the other's whereabouts, and ‘alin fo hood the mother’ calls By stopping ot ‘turning to her side. When hurt of nee children wth this frm of deerdered Sache tnd to ignore oF to rebut te mother or even 0 tse Out a her aggressively rather than to sek comfort from her. The cd's aggression deo may’ be cirecte towards him or Reset, with biting, iting, or headbong- ing. These Behaviors go well beyond occasional tantrums in response t rt thon and more pervasively characterize the hl’ responce to ned ot co The patter is se-endangering because the child fas Yo wze the mother as safe haven to which to feturn an tanes of danger, Decals the child repeat Secks dangerous stations or because the chi aggresive behavior i ict) felt-punitive or atleast likely to provoke aggression from caregiver, Rickles, scl-endangeiing toddlers Invariably show conctrrent manifests- tions of ancy. The ansely tay take a variety of forms including separdion protest, hypervigflance about the parent's whereabouts (which contrasts with the eptious of sudden bling away) niece ant prolonged temper tants, tinpeciable crying, mulips fears, self-damaging behaviors sich os headbang ing are eeltbiing nd enrol These sroely feactons ave cen overockad in ue asessnent proces becise the acidentsprone befavios and aggression sre so compiling that they galvanize the adult perception of the cud A full apprection of the under anety, however, i exsenta fora comprehraive sSteement and an effective Weatment plan Case Example Jeremy, 24 monlhs ol was refered by a welfare ageny for asssoment ana Ictat not beers Concerre abou hil deveopten ut ose way of Surin psychological teatnent fr his 17-year mother who had 2 i of ing Eater by Jeremy ne a well bythe nthe of her ond Sager in te coure ofthe assests teenth fre ho severe cocina fins of celf-endangering behavior id not heed his nae’ warning, and did not ook to fer for comlort cen fe was hurt seared Im everyone ofthe ive hhometsed sisensmentsersiene, Jeremy ron ahead af the ads when fe an Ns maser accompanied te Drerapist to her carat the en ofthe seson. He Git mst Cooly ih for mors cal nop ane tral fi bry and on br cxcastons the mother Barely had time to reach hen before fe ceached the sve imrection. When his mother caught up with hin, Jetemy screamed and ted to erage out of her arms. The mother reported at this behavior Was ya Of fermy and che seidom iook im on tings a 9 res Jeremy’ hehavior at home was eqully unbound, In session ater seston, the therapit reports malipie episode of ferony runing wid, chimbing on furniture and invari fling and hurting him. x none of tess episode Gi Jeremy neck out his mother although her emotional importance to im Was Spparent fom the way Re sought to displace hi itr from the mother Tap an ooked on sadly a8 the mother ply withthe bby. Jeremy did 0" show Sinetedaggremon tears his mot, But he repented Rt his str for MO DDSORDERS OF ATTACHDMENT IN INFANCY 581 apparent reason. The mother’s behavior, in tum, can best be described as ‘verging on sadicm and encouraging Jeremy's recklessness. One particularly poignant scene is deseribed in the therapists notes. Mother is chasing Jeremy with @ hand puppet and she hits him {aceidentaly?) in the head, pushing his ear into the edge of a sharp toy. He lets out a scream and she ties to convince him that he is hot really hurt, This 6 the first of many “accidents” Jeremy has during the hav, including several falls. The friction continues to build, Jeremy goes tothe door which leads to the back patio and his ‘other is shocked to find out that he has figured out how to open 3. He runs out, holding a pumpkin basket, saying “bye bye, bye bye.” The mother and [follow Jeremy a3 he walks towards the gate, continuing to say "bye bye.” The mother says. “Bye bye. See you later, Bye bye.”'| watch the scene and after a minute I retrieve Jeremy, telling him: “Jeremy, I'l really miss you if you leave-" We walk Back together and he ties to climb up onto a ledge, His mother {ssists him but does not hold on to him. He is precariously balanced ‘on this ledge, walking back and forth. I sit down on the ledge and But in ony apa ok Hi He folio me and ss ay for a few minutes. He then wreslles away and starts walking Ales around the room. During this ine the mother comments ‘on how hard Jeremy isto cleal with and how “good” her daughter is. ‘After heating this comment, Jeremy falls twice in quick succession. This scene conveys the mother’s active participation in the genesis and reinforcement of etry’ sell-endangering beavior By temperament Jeremy i Jn active child, but ativity level fase does not Bead To persistent el Sndangerment through recklessness, defiance, or aggression. Such a pattem Stems ‘from an atachment dno in which the childs inleraizing, the tnessage f anger an! rejection conveyed by the mother ‘Attachment Disorder With Folo Reversal ‘This pattern is characterized by precocious competence in self-care and self protection, withthe child faking over many of the caregiving fonctions or Rarly performed by the altachment figure Infants and toes with hs atlach- tment disorder patern seem to be umisually competent in keeping track ofthe rive whereabouts and in resting proximity and conlact hen Necessary. hoy show ei a tousnese towards their caregiver; that iy They are instantly aware of the aduls changes in mood and engage in sge-inapproprate foun of erating behavior Th pri carting aerate with ‘outbursts of angry, punitive, or contralling behavior, where the child sks out atthe parent of ia petulant manner tells he parent what to do “Tis clinical picture has been descr by Bowlby” and elaborated by Lieberman and Pav Zeanah and Kiitke™ and Zeanah etal? Research find- ings validating this category with older children were reported by Greenberg ot al™ and Main and Cassy." Case Example Larry, 30 months old, was referred for an infant mental health assessment at the advice of his father’s therapist, who became concerned by the child's ‘contro over the parents’ daly routine and their decisions about caregiving 582 LIEBERMAN & ZEANAIL During the assesament, Lasky einerged as a cnisually intelligent and verbal child who could not tolerate not being at she center of the conversation, ‘When the parents spoke with each other or withthe therapist Lary invariably found a way of restoring attention to hime, ether By saying something pavticully precocious that elicited admiration ad praise, showing of «draw: fig. he hot!'made, or other attentionatracting behaviors. His, parents were clevely very proud of Lary’s cognitive accomplishments and tonded to Jet him lake the lead” When his mother wanted to lewve the room briefly, she asked jermission from Larry to do 80. He got angry and sadn and insted on Rong {ith her, request Wat she granted. Throughout the session, I wae cer that Larry st ihe tone of the interaction and that hs parents defered to hits. Both parents said that they seldom went out or eacalied with friends in Latry’s Bbsonce because the child protested ther leaving and war inconsolable until dheir return. The parents attbuted ths to Larry's temperamentally determined sensitivity and. alleved it would damage him to be allowed to cry for a Tong time ‘Larry's control over the family was counterbalanced by deep anvictis about is parents’ wellbeing. When Is mother looked sad or serious, Larry asked, ‘Are you all ight?” and approached her with a concemed expression. It his father’ was late feom ‘work, Lamy asked why and worted about What had hhappened 0 him. When the parents had a disagreement, Larry would say “Stop. Make nice.” He had avery low tolerance for negative emotions snd lat looked for reassurance that things would be allright. Disrupted Attachment Disorder: BereavemenvGrief Reaction This catgory ie hated on the premise thatthe loss ofthe prima attach sment tigre i nerenly pathogen in nfany because the cla doesnot yet fave the pesonabty state Ge the Copntve and emotional esoures) to Cope adaptively with the los. Even wen the child ls eventually ae to ander the attachment bond to ne ctepver, ea of abandonment sha ulreabiy totes ae ely operat Los ofthe primary atachnen figure shoul always te teal as Pak fk it onrly- dtvedopenert ape br chiles venpeteny shoud bei mantores eft Sod be ne sap he sia and Cinoional svat to the ld tne allah fig, ae ince a provide he child with a subtitle primary altcunent igure. This rnc Can Be atiesad though behaviors dura ofthe stjuance of rote de spait, and detachment orginally dese by Robern and Adopt! by Hong! Th cid may crcl ond sarc forthe abeant paren recing te heigl of oles ta prove confer Ematical uaterevl ney be prea ws Lethargy, sd aca exprion, an lick of interest In ageappops ‘tivities Eating and sleping may be disrupted, an there tay be» hse OF repression inthe achevernt of developmental milestones (oy teverting fo bed sreling or baby talk), Detachment may appear in ne form of eceming tne ‘nee wards tauindure of the atadnene figure, sich a6 2 photograph OF Suton of his her ame, ot eelectve “forging.” euch te apparent ik of recognition of these cues’ Alerately te child might become extaely tceclve to slndor of the atscunent igure or teast eth Seong tot Sny theme remotely conned with separiion o los, such so rolual fo py iidsand-setk or bursting int teat he placement ofan everyday object DISORDERS OF ATTACHMENT IN INFANCY 583 Case Example Maeve, 17 months old, was refered for an evaluation 3 months after being transferrad to an adoptive home from a foster home where she had been since she was 3 months old. The child had responded to the los of her foster mother by crying inconsolaby, searching for her calling out her nave, and waking wp luring the night. These behaviors lasted for 2 weeks, receded gradually, and hhad. disappeared by the time of the referral. Maeve was now friendly to her adoptive parents and had even begun to show spontaneous affection towards them. She had developed three symptoms, however, that wortied her adoptive parents. The frst sympiom involved outbursts of rage. She had severe and Prolonged tantrums at the slightest frustration, throwing herself on the Door, Kicking at her parents when they attempted to comfort her, screaming, and banging her head on the floor. Her second symptom consisted of bursting into cars whenever ahe lost sight of her adoptive mother even for a few minutes, and refusing to be consoled by anybody els, including her adoptive father. Tho third symptom involved her rigidly and obsessively hiding litle tys in odd places: under her pillow, under her bed, under the rug, inside 2 cup or a pot. Through these three symptoms, Maeve was conveying her continuing [preoccupation with separation and loss and reenacting the psychological disinte {tation she had expertenced atthe loss of her beloved foster mother. ASSESSMENT Atlochment disorders are by definition relational disturbances, As a result, the assessment procedure needs to involve a comprehensive evaluation of the child's relationship with the primary caregivers. Optimally, the assessment Should ince observations of the child in the setings in which and with the ppeople with whom she or he spends considerable periods of time. In addition Torthe parents this often includes the childcare setting, regular babysitter, foster pase stepparents, grandparents and children who rein eg contact with ‘Given the variability of infant biologic states and moods, it is best to observe the child more than ance in different naturalistic settings. An adequately thorough evaluation often spans between 4 and 6 visits. This period should be designed not only to achieve an accurate and encompassing diagnostic picture bat ako to develop a working allance with the parents or caregivers tat will serve as the foundation for a successful recommendation for treatment oF other therapeutic interventions. “The parental motivations and expectations are an inhecent component of the asiessment process. Infants are referred from a varety of sources, and the roferral source influences the parents” perception of the referral Referrals by the courts or Child Protective Services have an implicit or explicit coercive compo- rent that affect the parents’ willingness tobe forthcoming about thelr practices, belief, and feelings about the child and about their own experiences. At the ‘ther extreme, parents who ate concerned about their child's development and ‘seek mental health services by their own volition are likely to be less worried aioout self-disclosure and lest suspicious oF defencive about the assessor's i ‘iris, ‘An tnderstanding of the child's functioning in the physical, motor, cogn tive, emotional, and social domains is important for differential diagnosis, prog- nosis, and planning of intervention strategies. Ths information may be gathered 584 LINDERMAN & ZEANAKL in the course of repested observations and supplemented with stctured assess tment procedures sich as developmental tes ‘toll, thorough understanding. of the family context is essential to fain a sense of how the chill “his in with the parents ond ther family Premera of he rntal reatioti a he paren rein ‘wth their ether children and with thee own parent, the parents” paychological Tncning tuding psyconk Gagne) We sues ond edie tors areal integral parts oF the pichre ‘TREATMENT Perhaps the most extensively shidied method of treatment with atlachment disorders Is infant-parent psychotherapy "8" This method of intervention is grounded on psychoanalytic object relations and attachment theories and integrates insightoriented psychotherapy with developmental guidance and 4 proactive stance on the resolution of concrete problems of living (eg, inadequate Fousing, insufficient food, mediocre or inconsistent medical cae) that are often faced by high-risk families and have a negative impact on the parent-child relationship. ‘The relationship disturbances that culminate in attachment disorders may’ have three differ and often overlapping sources, ea eli es a a cra an see rte cron diene ie Se earn Ea He ae ah a ern ete ee Ha oe reo py email co eae 4 RT ass vy easel tal ge alte Hoare 20 ray Oe mete vr ent in i Pepa cs ee Sane ce Oe a gel are 6 reece eo St see oer a ce of ura In many situations these three sets of factors coexist and aggravate each ‘other, creating an exponential negative effect on the parent-

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