Working with Young Children
with Attachment Disorders and
Their Families
Tuesday 10 June 2014
12:30pm - 2:00pm AEST
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Dr Dianne Camilleri
Clinical psychologist
Private practitioner
Professor Louise Newman
Infant psychiatrist
Monash University Centre for
Developmental Psychiatry & Psychology
Facilitator: Harry Lovelock, APS
Working with Young Children with
Attachment Disorders and Their
Copyright Dr Dianne
Camilleri (June 2014)
Outline of Presentation:
 A comment on the title of the presentation
 Attachment theory – overview and key concepts
 How does attachment theory help us understand
our work with families?
 Aim of therapeutic work with infants/children with
attachment problems
 Treatment with children experiencing attachment
based difficulties
 Case example
Copyright Dr Dianne
Camilleri (June 2014)
Introduction to the Title of the Presentation –
Differentiating ‘disorder’ from ‘disturbance’
 Title implies a more diagnostic category. HOWEVER, intention was to present
more diverse attachment difficulties, rather than specific disorders.
 Formal attachment disorder is represented in diagnostic classification systems
(such as DSM-V) as:
 (1) Reactive Attachment Disorder;
 (2) Disinhibited Social Engagement Disorder.
Both disorders are seen as distinct/unique disorders.
These disorders are not commonly diagnosed, and are diagnosed more in high
risk populations (10-20% of the severely neglected group of children).
Zeanah (2010) suggests “… an attachment disorder is warranted when a child
who is developmentally capable of forming attachments, does not because of an
aberrant caregiving environment” (p. 31).
Todays’ presentation will focus on a broad range of attachment
difficulties/disturbance, not just attachment disorders.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Definition
• Attachment as an evolutionary imperative. It represents:
• “a child’s biological tie or bond to her primary caregivers, usually
her parents. It is a biological system developed through
evolution to protect the child, thus ensuring the likelihood she
will grow into an adult and reproduce, thereby guaranteeing
gene survival.” (Newton, 2008, p. 9).
• Attachment works on the premise that we are ‘hard wired’ to seek
out relationships with others that promote our physical and
internal/psychological sense of security.
• Attachment tells us about the child’s primary relationships and how it
influences their development (eg social, emotional, cognitive).
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Characteristics
• Attachment theory has its origins with John Bowlby.
• Four key characteristics of attachment:
• (1) proximity maintenance (wanting to be physically near to the
persons we are closest to);
• (2) safe haven (returning to attachment figure when feeling
frightened or sense of threat (perceived or real));
• (3) secure base (the attachment figure represents a secure base
from which the child can explore their environment and other
• (4) separation distress (anxiety when attachment figure is
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – ‘Monotropic’ view
• Bowlby’s concept of ‘monotropic’ attachment (ie preferred
atttachment figure (usually the mother) above all others).
• This view limited? Especially in current social and familial
context – eg while mothers are still the primary caregiver for
most children, infants/young children can have multiple ‘key’
caregivers (eg both parents being very involved in the care;
grandparent providing part-time care while both parents work;
childcare environments; etc).
• Rutter (1995) also questions this monotropic view.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Key Concepts
• Attachment behaviour (observable) is activated
in response to fear or separation from
attachment figure and when infant/child
perceives real or imagined threat exhausts their
capacity to cope (Taylor, 2012).
• Attachment continuum – child moves between
proximity seeking and exploration.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – ‘Styles’ of Attachment
• Attachment ‘styles’ – emerged from work of Mary
Ainsworth and others following extensive observation
and research of separation and reunion behaviours of
infants ~1-2 years old.
• Technique used to identify these styles was called ‘The
Strange Situation’ (see attachment that follows for
procedures from Prior & Glaser, 2006, p. 100).
Copyright Dr Dianne
Camilleri (June 2014)
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – ‘Styles’ of
Attachment (cont.)
• Attachment styles identified by Mary Ainsworth:
• Secure (62-66% of children)
• Insecure
• Anxious-avoidant (15-22% of children)
• Anxious-ambivalent (9-12% of children)
• Disorganised (category identified by other
researchers, 15% of children) – Louise to focus
more on this one
(See following slide for descriptions of secure, avoidant
and ambivalent attachment styles – excerpt from Karen,
1994, p. 444-445)
Copyright Dr Dianne
Camilleri (June 2014)
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Secure Attachment
• Secure attachment:
• develops from a relationship with primary caregiver(s) which
provides a range of important characteristics/features such as
and responsiveness, including attunement,
availability, understanding, warmth, and consistency (at least
most of the time);
• provides an opportunity for the child to gradually and
increasingly explore their world beyond the primary
relationship(s) to other relationships and experiences, knowing
they can return when needed (during moments of feeling
fearful/insecure again).
• Secure attachment experience is eventually internalised (or taken
into their minds as a mental representation), allowing child to draw
on this internal sense of felt security without the actual presence of
the caregiver. Refer to this as ‘internal working models’.
Copyright Dr Dianne
Camilleri (June 2014)
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Attachment styles (cont.)
• Secure, anxious-avoidant and anxious-ambivalent
attachment are all considered ‘organised’ forms of
attachment – ie there is consistency in the infant/child’s
attachment behaviour under stress.
• Disorganised attachment, as the name suggests,
describes children that lack an organising framework for
their attachment experiences and lack a consistent
response in their attachment behaviour (eg can exhibit a
range of confused responses, include secure, avoidant,
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Attachment styles (cont.)
• For a brief video clip of a child with ‘secure’ attachment,
While viewing this clip, refer back to descriptive table for
‘secure’ attachment behaviours in infants.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Stability of Attachment
Styles Over Time
• Once developed, attachment styles remain relatively
stable across time (without changes in caregiving
environment that is).
• The younger the infant, the more malleable the
attachment style.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Association Between
Parenting Styles and Different Attachment Styles
• Parenting styles associated with anxious-avoidant
attachment (Newton, 2008):
• limited care of infant’s needs;
• frequent rejection of infant’s need for proximity and
sensitive care;
• tendency to encourage greater autonomy than is
health or developmentally appropriate for the child.
• These children often present with a false sense of
independence and tend not to seek parents out for
comfort or safety.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Association Between
Parenting Styles and Different Attachment Styles
• Parenting styles associated with anxious-ambivalent attachment
(Newton, 2008):
• inconsistent care;
• heightened focus and response to fearfulness in infant which
exacerbates the infant’s fear;
• discourages exploration (due to parental anxiety).
• These children often give mixed messages to the parent –
simultaneously hostile and dependent toward parent.
• They are hypervigilant to possibility of separation from attachment
figure, and seek to be proximally close even at times seemingly not
necessary (eg clingy behaviour) due to uncertainty about the
parents’ ongoing availability.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Limitations of
• While categories are important, need to keep in mind
that infants/children can exhibit different styles under
different circumstances or with different caregiver(s).
• What is more relevant to attachment ‘style’, is knowing
from your assessment (and formulation) how their
attachment style manifests, or plays out, in the child’s
relationships with others.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment and Post-Natal Depression
in Mothers
• Impact of PND on infants’ attachment – depending on level of
‘buffering’ by others (eg partner, extended family, other supports),
infant attachment may be quite compromised.
• Research suggests that while mothers who receive treatment for
their PND get better (ie symptoms resolve), any negative impact on
the infant’s attachment is not automatically corrected as a result.
• Mothers often feel tremendous guilt during episodes of PND and
later in relation to their lack of emotional availability (or even
physical neglect) during their episode of PND.
Copyright Dr Dianne
Camilleri (June 2014)
Attachment Theory – Whose Attachment?
• When we talk about attachment in relation to
infants/children, we are referring to the infant’s
attachment to their primary caregiver(s), not the other
way around!
Copyright Dr Dianne
Camilleri (June 2014)
How Does Attachment Theory Help Us
Understand Our Practice/Treatment
 Provides a framework for understanding a child’s relationships with
attachment figures, and how these relationships influence other
relationships in their lives, and their behaviour, self-concept, etc.
 Helps us understand the child’s relationship with us as the
therapist, and others in their life who aren’t in their immediate
caregiving system (eg teachers or peers at school; their dance
teacher; meeting new people).
 However, attachment is only part of an Ax with an infant/child, it’s
part of my understanding of a child’s difficulties.
Copyright Dr Dianne
Camilleri (June 2014)
Assessing Attachment
See notes attached.
Attachment to presentation by Dr Dianne Camilleri on ‘Working with Children with Attachment
Disturbance and their Families’ on 10 June 2014
Trying to develop an understanding of both the infant/child’s and the parent’s attachment
(both the observable behaviour and mental representations of attachment) will be
important. Some aspects of your Ax may include:
Infant’s/Child’s attachment:
observation of how the child manages separation from parent(s) during individual
assessment (use with children ~4 years and older); how do they respond to the
separation? Eg crying, clinging, refusing to go with you to, go with you but do not
explore the consulting room and toys once inside, frequently ask when they can go
out to their parent or wanting reassurance that their parent is in the waiting room,
observations during family or parent-infant/child interview – how is infant/child
relating to parent; does child seek comfort at any stage; if so, how does parent
respond; how in tune with the infant/child is the parent [eg the infant signals she is
tired, but the parent interprets this as the infant wanting to be put down on the mat
to play with the toys];
observation of infant/child and parent(s) playing together (instructions may be
something like: “I’d like the two/three of you to just play freely as you might at home
together, and I’m going to sit back and not be involved. Try and forget I’m here (I
know that’s difficult). We’ll do this for about 10-15 minutes.” Purpose of doing this is
that it is (a) unstructured; (b) produces a little bit of anxiety which will make the
attachment style more overt; (c) see how the child initiates comfort from parent,
proximity seeking, is there reciprocal interaction, evidence of symbolic play; for
older children, how does conflict get managed (eg does it emerge and how is it
responded to/dealt with/managed – also looking for how the parent is managing
this; eg does the parent try to shut things down, do they respond with anger, do
they freeze, do they criticise, do they follow the child’s lead or do they lead the play,
what does the child say (if old enough) about his/her relationship with
pay attention to transitions – often children with attachment difficulties find
transitions difficult – could be transitions to bedtime, to school, to childcare, etc, as
reported by parents and child.
Parents’ own attachment history:
Parents’ own history is important as it will provide information as to their attachment
experience in their family of origin. Important as there is a strong correlation
between parent’s attachment style and their infant/child’s attachment style. Eg
insecure-dismissing parents tend to be associated with more avoidant style in child
and they tend to overly encourage autonomous behaviour; insecure-preoccupied
parents tend to be associated with insecure-avoidant style in child and feel anxious
about their child’s exploratory behaviour and so discourage it (Prior, V., & Glaser,
D., 2006, p. 51).
Copyright Dr Dianne
Camilleri (June 2014)
What Are Some Possible ‘Red Flags’ That May
Suggest Attachment Based Difficulties?
• In infants, some ‘red flags’ may be:
persistent settling, sleep or other regulatory problems;
persistent crying;
gaze avoidance;
frequent/persistent irritability;
feeding difficulties;
tantrums, biting, aggression, etc;
bonding difficulties;
loss of significant attachment figures;
infants with chronic ill-health;
history of trauma.
Copyright Dr Dianne
Camilleri (June 2014)
What Are Some Possible ‘Red Flags’ That May
Suggest Attachment Based Difficulties? (cont.)
• In pre-school or primary school aged children, some ‘red flags’
may be:
• separation difficulties;
• no clear preference for their primary caregivers;
• relational problems with peers that is unexplained by a pervasive
developmental delay or ASD problem;
• excessive and intense ‘temper tantrums’;
• regressions in milestones;
• difficulties in developmentally appropriate exploratory behaviour;
• excessive shyness, sensitivity and/or fearfulness;
• loss of significant attachment figures;
• history of trauma.
Copyright Dr Dianne
Camilleri (June 2014)
Aims of Therapeutic Work with Children with
Attachment Based Difficulties
The aim of therapeutic work with families is to:
increase the security of the infant’s/child’s attachment relationships with
their primary caregivers, and thereby with others;
increase parents’ reflective functioning [see comments to follow, but
essentially thinking about thinking/feelings rather than reacting/judging];
alleviate the presenting difficulties that the child is exhibiting that you
believe have insecure attachment at their core;
helping the parent connect with their child in a more authentic way,
without their past history contaminating their relationship with their
infant/child, and being able to be more responsive to the child’s needs;
helping caregivers and their children create opportunities for repair in
their relationship (ie responding/interacting/thinking differently).
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Importance of a
Good Formulation
Good beginning to treatment is having a good formulation (which follows on
from your assessment).
See attached notes regarding important aspects of the formulation.
Attachment to presentation by Dr Dianne Camilleri on ‘Working with Children with Attachment
Disturbance and their Families’ on 10 June 2014
Attachment theory is usually only part of the story - it won't always explain everything,
& this is where a initial period of Ax and good formulation and understanding of child
development is important.
The basis of any therapeutic work is a good formulation. A good formulation
should be based on your assessment of the child’s difficulties. This will include the
questions of ‘What factors may have influenced the infant’s/child’s presenting
problems’, ‘What is continuing to maintain the infant’s/child’s presenting problem(s)?’,
‘What strengths are there in this infant/child/caregiver(s)/systems supporting the
child/family?’. Sharing key aspects of your formulation with parents will form the basis
of your treatment and is a crucial beginning to any treatment, because:
o it lets the family know you have been listening and that they have not given all
the assessment information in vein;
o shows the family you understand the child’s difficulties and their struggle as a
o provides an opportunity for a shared understanding of the child’s difficulties – if
not, the therapy is unlikely to flow on positively from your Ax;
o provides an explanation that you will continue to reflect on and use in the
therapeutic work (eg reiterating patterns that are unhelpful in the child-caregiver
o acknowledges that all behaviour has meaning – aim to understand the meaning
underlying an infant/child’s behaviour, or overt presentation, rather than the
behaviour being an isolated and random occurrence that can be treated in
isolation of their relationships with others;
o it begins the psycho-education process embedded within the work.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Important Definitions
Some important definitions:
Reflective functioning – Slade (2008, p. 214) describes reflective functioning as:
“Reflective functioning can be understood narrowly as the capacity to
understand one’s own and others’ behaviour in terms of underlying mental
states and intentions, and more broadly as a crucial human capacity that is
intrinsic to affect regulation and productive social relationships.”.
This capacity is narrowed or limited in some parents, and consequently
underdeveloped in their children who develop insecure attachments. It is about the
capacity to reflect rather than react or judge the child, and to make sense of and be
open and curious to internal states and experiences of oneself and one’s child.
Eg your child throws your favourite ornament on the floor out of anger and it cracks.
Rather than react (punish, express anger toward the child, tell the child their
behaviour was bad, etc), you think about what may have lead your child to act this
way, why that ornament, what do you think he was trying to achieve, do you think he
understood the significance of the ornament, and so on.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Important Definitions (cont.)
Some important definitions (cont.):
Ghosts in the nursery: central idea to working with parents. It refers to the negative
influences on current relationships (ie with one’s infant/child) from past
relationships/history. Fraiberg, Adelson, & Shapiro (1975) state:
“In every nursery there are ghosts. They are the visitors from the
unremembered past of the parents, the uninvited guests at the christening.
Under all favorable circumstances the unfriendly and unbidden spirits are
banished from the nursery and return to their subterranean dwelling place. The
baby makes his own imperative claim upon parental love and, in strict analogy
with the fairy tales, the bonds of love protect the child and his parents against
the intruders, the malevolent ghosts.” However, in some circumstances, “…
The intruders from the past have taken up residence in the nursery, claiming
tradition and rights of ownership. They have been present at the christening for
two or more generations. While no one has issued an invitation, the ghosts
take up residence and conduct the rehearsal of the family tragedy from a
tattered script.” (p. 388).
Copyright Dr Dianne
Camilleri (June 2014)
• Empathise with how difficult it may be for both parents & infant/child.
• Encourage/promote consistent, sensitive, responsive, attuned,
caregiving and replicate this in the therapeutic relationship.
• The therapeutic relationship needs to mimic secure attachment
characteristics – eg therapist provides consistency (environment
and time), reliability, attunement (to both parent(s) and infant/child),
reflective capacity, containment by therapist (ie ability of the
therapist to tolerate the intolerable feelings/thoughts/etc of the
parent(s) and/or child.
• Explore what is getting in the way of parent providing this (go back
to your formulation and observations for this).
• Help families to create new ways of relating through play, and
exploratory discussion in order to increase their capacity to reflect
and to offer what their infant/child needs.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Some Guiding Principles
• Tools you may use to create reparative conversations with the
parent(s) and child: photos (may be recent, may be when child
was an infant) or special objects (eg a baby blanket that has
special meaning; baby’s first tooth; etc – bring into the room
something very real about the family;
• Attempting to use in vivo moments in the sessions to explore
the parent-infant/child relationship (eg the child seeks comfort;
there is conflict in the session; the parent doesn’t know how to
play with their infant/child; etc).
• Use of play with infants/children and parent(s) as a way of
engagement and therapeutic change.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Some Guiding Principles (cont.)
• Some parents have a lot of trouble just ‘being with’ their child
or playing with or enjoying their infant/child. This may be due
to their anxiety that they have nothing to offer, that they have
too many competing demands, that they dislike their child, etc.
However, if the relationship between child and parent(s) is to
improve, developing a sense of comfort in being in each
other’s company (without judgement/criticism, etc) is crucial;
the therapist here is a facilitator/bridge between the
infant/child and their parent(s).
• Observations of the parent-child interactions or the play.
• One approach that uses a reflective stance in parent-infant
work can be found in an approach developed by Muir, 1992
called ‘Watch, Wait & Wonder’. (See reference).
Copyright Dr Dianne
Camilleri (June 2014)
Who is Involved in Treatment?
• Who is involved in sessions?
• Parent only – child-focussed (although with infants, almost
always see parent-infant together – some exceptions).
• Parent and infant/child joint sessions.
• Alternating between parent-child and child-focussed parent
• Important that parents are always involved in treatment,
especially given attachment disturbance occurs in a
relational context (see Slade, 2004 and Hopkins, 1991).
Copyright Dr Dianne
Camilleri (June 2014)
Treatment –
Parent-Infant/Child Joint Sessions
• What might a parent-infant/child session look like?:
• Brief ‘catch up’ period at the beginning of session. Keep ‘ear
open’ for differences reported (eg “We had a good night last
night. He slept through and I felt well rested this morning. This
hasn’t happened for months”).
• Invite parent to play with their infant/child (may need to model
this to parent (eg get down on the ground first; say “come and
join us down here” [unless infant newborn]).
• Once play has got going, watch, wait and then may wonder out
loud with parent or make observations about play – eg parent
and child at dolls house: “I notice there is a lot of fighting in this
[play] family”; may ask parent “I wonder what you think is going
on in this play at the moment?”.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Parent-Infant/Child Joint
Sessions (cont.)
• We are assisting parent(s) to develop greater reflective capacity. Eg.
child may throw a toy at the parent and, say, parent withdraws from child.
Could use this as an entry point for exploration – what is the parents’
experience of this interaction? What does parent think is child’s motive?
What do they think this was about for their infant/child (eg defiant? sadistic?
lack of self-control? etc).
• May offer observation: eg “I wonder if you withdraw from Sam when
he throws something at you as maybe having something to do with
your earlier comments that you believe you are a hopeless parent?”.
• There may be room to guide/coach the parent to respond differently
(eg “What do you think would happen if you took the toy & returned
it to Sam and said “I’m not sure what just happened between us?”
and ask parent to think about how Sam might respond.
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Child-focussed Parent Work
• Child-focussed parent work (not the same as individual therapy for the
• attempting to help parents enhance their reflective functioning capacity;
• explore parent’s history, their negative feelings toward their child (eg
“when I look at him I see is a monster”), or their lack of self-confidence
as a parent (eg “I have nothing to offer my child”);
• help parents to disentangle negative aspects of their own histories from
intruding into relationship with their infant/child;
• psycho-education about infant/child emotional functioning;
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Child-focussed Parent Work (cont.)
explore the parents’ projections (eg asking parents to think about where their
perceptions, feelings, thoughts, etc, about the child belong);
explore their perceptions and interpretations about their infant/child’s behaviour
(parents will make their own interpretations about the meaning of their child’s
behaviour – eg: “he’s just wilful – he just doesn’t want to go to bed”; “she is
manipulative – she will just constantly want my attention”; “she is fiercely independent
– she never wants me to comfort her, even when she hurts herself badly”; etc0;
Example: 7-year-old boy who has always reminded his mother of her violent exhusband (boy’s father) – gently helping her to understand that this does not belong to
her son and his and her relationship – eg “In what way is Eli different to your exhusband?” or “How is Eli’s anger different to your ex-husband’s anger”; etc). Could
perhaps point out differences you have observed/heard as part of the therapeutic
conversations and checking out your observations with the parent (eg “I’ve noticed
that when Eli gets angry with you, once he has calmed down he doesn’t ‘hold a
grudge’ like you say your ex-husband used to after he was abusive. What do you
Copyright Dr Dianne
Camilleri (June 2014)
Treatment – Child-focussed parent work (cont.)
Slade (2008) describes some ways of working with parents to enhance
parental reflective functioning:
 creating a context for meaning making, or a thinking space;
 we hold the parent in our mind (as the therapist);
 we hold the infant/child in mind until the parent can hold their infant/child
in mind (don’t expect the parents’ capacity to be very high at the
beginning of treatment);
 we model a reflective stance (eg if a parent is overtly verbally attacking
us (“You don’t have an f……. clue”), that we don’t respond with
reactivity or defensiveness, but instead wonder with the parent about
the experience of feeling helpless, or angry, or disappointed by me, or
 working at a level the parent can manage (going at the parents’ pace);
 being flexible in the way you work.
Copyright Dr Dianne
Camilleri (June 2014)
Case Example – ‘Chloe’
Chloe – 3.5 years. Referred due to:
• frequent and intense tantrums (++daily), would become highly distressed,
demanding, scream; despite seeking comfort, she was often unable to use
comfort offered by parents [characteristic of ambivalent attached children]
• described as being unhappy, often irritable or overtly angry and upset easily;
• family (particularly her mother) often gave into Chloe at times because they
could not tolerate her distress and to avoid escalation in her behaviour;
• extreme distress upon separation at childcare, where she had attended one day
per week for the previous two years; in the first year, she would cry on and off
the entire day; she made no emotional connection with any of the caregivers in
the two years she had been attending; their strategy to manage her extreme
separation anxiety was to ignore her, as they believed to try to comfort her made
it worse. In more recent times, she continued to exhibit separation distress, but
would settle within 10 minutes or so;
• Chloe was reported to be highly anxious even in very familiar social situations
[overly-anxious, compromised exploratory behaviour] (such as regular
attendance at her sister’s dance group with mother present where she would
stay constantly next to her mother throughout;
Copyright Dr Dianne
Camilleri (June 2014)
Case Example – ‘Chloe’ (cont.)
• she had some tactile sensitivities – frequent ‘fighting’ against her parents
when they needed to strap her into the car, the pram or bath her or
wash/brush her hair;
• difficulties going to sleep at night without one of her parents laying with her
until she fell asleep; [separation distress];
• both parents were overwhelmed by Chloe’s challenging behaviour, but
particularly Chloe’s mother who was her primary caregiver;
• Chloe was often angry toward her parents, and they found it difficult to offer
her comfort and support because of her mixed messages of wanting them to
support her, but being unable to be soothed [ambivalent attachment style]
• Mrs [X] talked about having moments of complete despair and had thoughts
of wanting to harm her daughter; underlying rage toward her;
• developmental history: unsettled as an infant; mother had expected to be
very competent in her parenting given this was her third child, but was
intensely disappointed when Chloe experienced sleep, settling and feeding
difficulties [‘red flags’ for potential attachment difficulties]
Copyright Dr Dianne
Camilleri (June 2014)
Case Example – ‘Chloe’ (cont.)
• mother would respond to Chloe’s need to be close to her inconsistently –
sometimes providing comfort and sensitivity, other times rejecting Chloe and
expressing angry feelings toward her; at bedtime, Mr [X] had to support
Chloe to get to sleep because Mrs [X] became too frustrated with her
[inconsistent parenting style of responding to proximity seeking
behaviour in child]
• History: mother had PND; Chloe conceived during period of significant
stress for mother in context of death of her mother during pregnancy
(complicated relationship with her); Mrs [X] felt belittled within her family
[which had left her sense of self as incompetent and she applied this to
her belief about herself as a parent]; extreme feelings of inadequacy as a
mother which were compounded by her depression; [++’ghosts in the
• Father had history of significant Hx of depressive and anxiety problems
(which would manifest at times with explosive anger outbursts); difficult
relationship with his own parents who were supportive but father passive
and didn’t manage conflict or emotions well; [ghosts in the nursery]
Copyright Dr Dianne
Camilleri (June 2014)
Case Example – ‘Chloe’ (cont.)
• individual assessment – Chloe found it very difficult to leave her mother in
reception; we decided to do a graduated transition to Chloe’s mother waiting
just outside the consulting room. Chloe was able to explore the consulting
room and toys some of the time; however, when I approached her with a
question, invitation to play with something, etc, she withdrew from me and
became more inhibited in her play;
• treatment included alternating sessions between (1) Chloe and her mother,
(2) mother alone and (3) mother and father alone;
• dyad work: Chloe would become angry with the initial ‘catch up’ phase, as
she didn’t like to have to ‘share’ her mother with me, so after a few sessions
of doing this, we decided to move directly into play when entering the
consulting room. Chloe had intense difficulty with the transitions [often
emerges with attachment difficulties] in and out of the sessions (not
acknowledging me at the start, but not wanting to finish and leave at the
end). The dyad sessions offered both Chloe and her mother an opportunity
to re-learn how to enjoy each other (something her mother had never really
felt with Chloe);
Copyright Dr Dianne
Camilleri (June 2014)
Case Example – ‘Chloe’ (cont.)
• dyad sessions were used to explore relationship, allow opportunities for
Chloe to seek closeness to her mother without rejection, thinking about
Chloe’s play and interactions with her mother and me;
• parent therapy:
• sessions with mother alone were focussed on her feelings of inadequacy,
her feelings of intense rage toward Chloe, her relationship with various
family members, her history, her complicated relationship with her deceased
• sessions with both parents – focus was on finding alternative ways of seeing
Chloe’s behaviour (eg rather than her behaviour as oppositional or uncooperative, seeing it as frightened) and thinking about how they were
responding to Chloe during times of distress/anger/challenging
• other aspects to the treatment: managing the transition to kindergarten –
gradually reducing maternal support, photos of the teacher (with permission)
and the kindergarten environment, visits to the kindergarten, using names of
kindergarten teacher & peers prior to starting. [providing support using
your formulation of her difficulties to guide her transition to kinder]
Copyright Dr Dianne
Camilleri (June 2014)
Copyright Dr Dianne
Camilleri (June 2014)
References for Further Exploration!
The following are some references that are not all attachment specific, but provide
good guidance for child-focussed parent therapy generally, and share many of the
same principles of attachment based thinking:
 Daniel Hughes uses attachment concepts extensively in his work. In his book
‘Brain-Based Parenting’ (2012), he advocates a model he calls PACE
(playfulness, acceptance, curiosity and empathy). He suggests paying attention
to these areas applies equally to the parent-child relationship and to the
therapist-parent relationship (to promote trust and connection).
 Slade, A. (2008). Mentalization as a frame for working with parents in child
psychotherapy (pp. 307-331). In E. Jurist, A. Slade, & S. Bergner (Eds.). Mind to
Mind: Infant Research, Neuroscience and Psychoanalysis. NY: Other Press.
 Rustin, M. (1998). Dialogues with parents. In Journal of Child Psychotherapy,
24(2), 233-252.
 Slade, A. (2008). Working with parents in child psychotherapy. Engaging the
reflective function. (pp. 207-234). In Mentalization: Theoretical Considerations,
Research Findings, and Clinical Implications. F. N. Busch (Ed.). NY: The Analytic
 Hughes, D. (2012). Brain-Based Parenting: The Neuroscience of caregiving for
Healthy Attachment. NY: W.W. Norton & Company. [Some helpful ideas
regarding managing emotion regulation in the therapy room – pp. 163-183.]
Copyright Dr Dianne
Camilleri (June 2014)
References for Further Exploration!
Family therapy approaches to working with attachment based
 ‘Attachment-Focused Family Therapy’ (book) – Daniel A. Hughes
(primarily used with families where child is in foster care, multiply
placed child, adoption).
 ‘Rewriting Family Scripts’ (book) – John Byng-Hall.
These approaches take a whole family approach to treatment,
recognising that unhelpful attachment patterns within a family may be
the protagonist for a child’s presenting problems and underlying
attachment difficulties.
Copyright Dr Dianne
Camilleri (June 2014)
References (used throughout presentation)
Berlin, N. (2008). Tripartite therapy with older children: mutuality in the relationship of a parentchild attachment. In Journal of Child Psychotherapy, 34(3), 335-363.
Bleiberg, E. (2002). Attachment, trauma, and self-reflection: Implications for later
psychopathology. In J. M. Maldonado-Durán (2002). Infant and Toddler Mental Health: Models of
Clinical Intervention with Infants and Their Families, (pp. 33-56).
Cassidy, J., & Shaver, P.R. (Eds) (2008). Handbook of Attachment. Theory, Research, and Clinical
Applications (2nd ed.). NY: The Guilford Press.
Fraiberg, P., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to
the problem of impaired infant-mother relationships. In Journal of the American Academy of
Child Psychiatry, 14: 387-422.
Fraiberg, S., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: A psychoanalytic approach to
the problems of impaired infant-mother relationships. In Journal of the American Academy of
Child Psychiatry, 14(3): 387-421.
George, C., Kaplan, N., & Main, M. (1996). Adult Attachment Interview protocol (3rd ed.).
Unpublished manuscript, University of California at Berkeley.
Hopkins, J. (1991). Failure of the holding relationship: some effects of physical rejection on the
child’s attachment and inner experience. In C. M. Parkes, J. Stevenson-Hinde, & P. Marris (1991).
Attachment Across the Life Cycle. London: Routledge, (pp. 187-198).
Karen, R. (1994). Becoming Attached: First Relationships & How They Shape Our Capacity to Love.
NY: Oxford University Press.
Copyright Dr Dianne
Camilleri (June 2014)
References (used throughout presentation)
Lieberman, A. (2002). Treatment of attachment disorders in infant-parent psychotherapy. In J. M.
Maldonado-Durán (2002). Infant and Toddler Mental Health: Models of Clinical Intervention with
Infants and Their Families, (pp.105-128).
Muir, E. (1992). Watching, waiting, and wondering: Applying psychoanalytic principals to motherinfant intervention. In Infant Mental Health Journal, 13(4), 319-328.
Newton, R. (2008). The Attachment Connection: Parenting a Secure & Confident Child Using the
Science of Attachment Theory. Oakland, CA; USA: New Harbinger Publications, Inc.
Newton, R. (2008). The Attachment Connection: Parenting a Secure & Confident Child Using the
Science of Attachment Theory. Oakland, CA: New Harbinger Publications, Inc.
Prior, V., & Glaser, D. (2006). Understanding Attachment and Attachment Disorders: Theory,
Evidence and Practice. London: Jessica Kingsley Publishers.
Rutter, M. (1995). Clinical implications of attachment concepts: retrospect and prospect. In
Journal of Child Psychology and Psychiatry, 36(4): 549-571.
Slade, A. (1999). Representation, symbolization, and affect regulation in the concomitant
treatment of a mother and child: Attachment theory and child psychotherapy. In Psychoanalytic
Inquiry, 19(5): 797-830.
Slade, A. (2004). The move from categories to process: Attachment phenomena and clinical
evaluation. In Infant Mental Health Journal, 25(4): 269-283.
Taylor, C. (2012). Empathic Care for Children with Disorganized Attachments: A Model for
Mentalizing, Attachment and Trauma-Informed Care. London: Jessica Kingsley Publishers.
Zeanah, C. (2010). Reactive Attachment Disorder: A Review for DSM-V. American Psychiatric
Copyright Dr Dianne
Camilleri (June 2014)
disorganisation and development
Professor Louise Newman AM
Centre for Developmental Psychiatry
and Psychology
Monash University
Neuropsychological processes
Affect regulation
Representations of self, other
Attachment Style
Adaptation to Stress
Capacity for intimacy and empathy
Perception of affective signals
Communication of internal states
Complex social responses
Environmental interaction and processing
“A pre-wired knowledge of the world” Stern
• Parents with unresolved traumatic attachment
issues and histories of maltreatment/neglect
• Range of issues and conflicts when they
attempt to parent – from anxiety to avoidance
to repetition
• Opportunity for the prevention of disturbed
parenting and abuse
• Parenting relationships which impact
adversely on child development and
particularly on security of attachment
• Spectrum of parenting behaviors, emotional
responses, attitudes and conflicts (conscious
and unconscious) which are traumatizing for
the child and result in disorganization of
attachment and impact on emotional and
behavioral regulation
• Influenced by parental attachment history,
reflective capacity and mental state
• Patterns of traumatising parenting are often
• Maltreatment, abuse and exposure to violence
in infancy are risk factors for later abusive
behaviour and revictimisation
• Prevention of child maltreatment involves
identification of high-risk parents and early
Trauma is reenacted in the relationship with
the infant
Unresolved parental attachment trauma is
reflected in the handling and care of the infant
Trauma disrupts emotional interaction and
• Human infants have an innate capacity to form
attachment relationships
• Attachment has species-survival value
• Attachment behaviour is organised as a goalcorrected system
• Attachment behaviour is present from birth
• Secure attachment is based on empathic,
responsive and consistent emotional care
• Security of attachment promotes
neurobiological and psychosocial development
and resilience
• Early caretaking experiences and the emotional
environment are the foundations of
psychological health
• The first two years are critical periods for the
development of emotional understanding and
attachment relationships
• Trauma and disruption in this period will have
implications for personality development and
mental health
• Attachment disorganisation represents a failure to
develop an effective strategy to deal with anxiety
about the carer – persistent unresolvable stress;
the “paradox of maltreatment”;
• Impact on models of self and relationships - trust,
thinking and reflection, self representation
• Intrinsic essential capacity for attachment
• Internal representations of self, other and
• Influence of separation, loss and disruption insecurity, self-concept, repetition of
dysfunctional patterns
• (1) Concerns a class of behaviour separate to
feeding and sexual behaviour.
• (2) Concerns relationships, rather than 'drives'
or 'energies' (Freudian model).
• (3) Differs from dependence.
• (4) Co-exists with exploratory behaviour.
Unprocessed traumatic memories
Infant as a projective focus –
Infant experienced as anxiety
provoking, persecutory, hostile
Patterns in high risk families
Distorted representation of the child
Parental preoccupation with past trauma
Parental anxiety
Parental deficit in interpretation of the infant
emotional communication
• Problems in interpersonal functioning\
• Limited reflective capacity
• Capacity to understand own and child's
behaviour in terms of underlying mental states
• Basis of parents ability to hold the infants
affective experience in mind
• Gives meaning to the child’s affective
experience and re-presents it to the child in a
regulated fashion
• RF is the basis of parental access to their own
emotions and memories of their own early
attachment experiences
• Mediates the reworking of parents early
relationships in the transition to parenthood
and representation of the child
• Impacts on interactive and parenting
• Crucial in establishment of attachment
relationship and emotionally attuned early
• Gives infant experience of being validated and
contained and is the beginning of self
• Mental representation of the self, the other
and their relations
• Formed from generalised representations
of events
• Include feelings, beliefs, expectations,
behavioural strategies and rules for
directing attention, interpreting
information on and organizing memory
• Models affect future relationships and
• Child may develop two conflicting internal
models of an important relationship
• Traumatic models and experiences may be
unconscious but still influence relationships,
feelings and interactions
• Mothers’ attributions, beliefs and feelings
about the infant reflect her own attachment
• Secure mother has capacity for sensitive
responsiveness and containment
• Maternal state of mind regarding attachment
influences the emotional, non-verbal
interaction with the infant
• Strange Situation Procedure - secure and
insecure patterns
• Parental responsiveness to infant affect and
secure attachment
• Longitudinal studies of attachment patterns
• Secure attachment promotes competence emotional, relationship, narrative, learning.
• Associated with trauma and abuse
• Lack of effective strategy for dealing with
• High levels of stress and related hormones
• Defensive exclusion of understanding of
• Excessive use of dissociation and opioid related
Poor development of internal state language
Poor reflective function
Deficits in empathy
Contradictory representations of self and other
Dysregulation of behaviour, affect and impulses
• Dysregulation of HPA axis functioning - stress
• Altered cortisol pattern- stress hormone
• Reduced volume of hippocampus- memory
• Reduced volume of corpus callosuminformation processing
• Potential effects on mood and impulse control,
emotional regulation
Adaptation - avoidance, repression, dissociation
Repetition – re-enactment, play, identification
Anxiety - arousal, aggression, self-harm
Self-Concept - depression, guilt, shame
Problems with interpersonal relationships
Problems with affect regulation
Ongoing vulnerability to stress
Self and other representations- negative
self-concept, mistrust of others
• Deficits in reflective function and empathy
• Syndrome of neurophysiological and
psychosocial dysregulation
• Symptoms as attempts to reestablish
• Basis in traumatic early attachment
experiences and neurodevelopmental effects of
• Relationship
• Self-destructive
• Affective
• Dissociation
• Psychotic-like symptoms
• Identity disturbances
Borderline Personality
Disorder - Psychological
Unresolved trauma and loss
Poor reflective self function
Disturbed self-experience
Disorganized attachment
Maladaptive defense style
• Dysregulation of affect and intolerance of
• Limited internal state language
• Contradictory representations of self and other
• Limited reflective capacity
• Unintegrated traumatic memories
Limbic irritability
Reduced size of hippocampus
Reduced left temporal lobe development
Reduced left-right integration
Reduced volume of corpus callosum
Decreased blood flow to cerebellar vermis
• Infant Behaviour - dazed behaviour on reunion;
freezing; expressions of fear and confusion;
strong avoidance followed by strong proximity
seeking; attachment behaviours in confused
• Maternal Behaviour - confusing,
frightening/frightened; history of unresolved
attachment trauma, loss.
• Parents with unresolved traumatic attachment
issues and histories of maltreatment/neglect
• Range of issues and conflicts when they
attempt to parent – from anxiety to avoidance
to repetition
• Opportunity for the prevention of disturbed
parenting and abuse
features of unresolved trauma impacting on
thinking and relational functioning limited RF
Impacts capacity to understand and process
affect and interactions
Associated with limited RF and affect regulation
High rates of disorganisation in borderline
personality disorder
• Secure attachment is based on emotional
• Attachment relationship regulates emotional
• Emotional competence and self-regulation
related to quality of early interaction
• Mutual attunement and synchronicity
• Regulation of overall degree of stimulation and
• Promotes development of self-regulation
• Process begins at birth
• The ability to attune to the infant’s signals,
interpret them correctly, and satisfy them
promptly and appropriately.
• Depends on learning the meaning of the
infant’s signals as they vary over time
• Different cultures value it differently
• Differs from spoiling and overprotection in
supporting child’s increasing autonomy and
ability to communicate
• Intervention studies include focused
interventions in the home, and sensitivity
training sessions with videotapes
• They have demonstrated that parental
sensitivity can be improved, by assisting them
to find alternative explanations for infants’
behaviour and alternative strategies
• Attachment disruption and emotional
misattunement will affect emerging capacities
for interaction and self-regulation
• Disruptions during critical periods and rapid
phases of development are potentially the most
• Trauma affects brain development
Neurophysiological changes
• Physiological studies indicate that insecure
children demonstrate high levels of stress, from
suppressing or otherwise not being able to have
their attachment needs met.
• This may have implications for the development
of psychosomatic symptoms and diseases
• Intrinsic infant problems - disorders of affective
• Dysregulated infant - prematurity, substance
exposure, maternal stress and trauma in
pregnancy, perinatal insult
• Maternal attachment factors - attribution,
expectations, own attachment history
• Anxiety about ability to nurture and feed the
• Fear of harming the dependent infant
• Feelings of aggression and resentment
• Guilt and depression
• Problems re-negotiating partner relationship
• Difficulties in establishing self as mother
• Mother feels persecuted by infant and
attributes hostile intent
• Infant becomes identified with traumatic
attachment figure/abuser
• Mother experiencing effects of early trauma
• Previous infant maltreatment and neglect
• Disorders of non-attachment - emotional
withdrawal, indiscriminant sociability
• Secure Base Distortion - inhibition,selfendangerment, excessive clinging,
hypercompliance, role-reversal
• Disrupted Attachment Disorder - limited
comfort from others.
• Affection - sharing, warmth; absence or
• Comfort seeking - failure to seek comfort or
seeking from strangers
• Help Seeking - excessive dependence,
premature competence
• Cooperation - noncompliance or hyper-
• Control - punitive/controlling with attachment
figure; overcaring
• Exploration - inhibition; dangerous exploration
without secure-base behaviour
• Separation and Reunion Behaviours
• Insecure attachment is not a disorder or a
disturbance per se, but a risk factor
• It appears associated with more behaviour
• Avoidant children have slightly more
externalising and internalising problems
than secure or resistant children
• Disorganised children have moderately
more externalising problems & dissociative
• The relationship between client(mother)and
clinician is an attachment relationship
• therapeutic bond, & the clinician as safe
base, is critical to the success of intervention
• Clinicians' needs to understand the mothers
inner working model of attachment
• Cognitive behavioral and
• Attachment based – importance of
parental capacity to perceive and
sensitively respond to child's emotional
• Without emotional attunement parenting
programs may improve management but
not the emotional aspects of the parentchild relationship
• Early intervention – antenatal, infant and
• Program incorporating focus on emotional
development and child’s needs for attachment
• Focus on improving maternal emotional
availability and reflective capacity
• Evidence for medium term programs
• The therapist functions as a reliable base
so that a secure attachment can develop,
despite the child’s attachment disorder
• Through direct interaction and observation
of symbolic play, the therapist enables the
child to express material regarding his
attachment experiences
• The therapist interprets attachment-related
interactions between himself and the child
Contact The ATAPS CMHS Clinical Support Service. Phone
1800 031 185 or email [email protected]
A recording of this webinar will be available on the APS ATAPS
Clinical Support Service web portal - see
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