Attachment-informed interventions with the perinatal population

With growing attention being paid to perinatal mood and anxiety disorders (PMADs) in both medical and mental health settings, there is a need for further elaboration on meaningful and impactful treatments with this population. This article outlines some of the unique stressors and psychological states that come with pregnancy and parenting a newborn and infant. The concepts and experiences discussed include: primary maternal preoccupation (Winnicott, 1956), parental ambivalence, major changes to the physical body, and reorganisation of attachment representations and current family dynamics. Clinical material from therapy sessions with patients at a specialised perinatal centre is included in the discussion of using an approach informed by attachment theory (Bowlby, 1988).

Maternal Attachment Representations during Pregnancy, Perinatal Maternal Depression, and Parenting Stress: Relations to Child’s Attachment

Background: This paper aimed to explore the associations between maternal representations of attachment evaluated during pregnancy, pre and postnatal maternal depression, parenting stress and child’s attachment at 15 months after childbirth. Methods: Mothers (n = 71), and their infants participated in a longitudinal study of maternal attachment, pre and postnatal depression, parenting stress and child attachment. Adult Attachment Interview (AAI) was conducted between 24 and 26 weeks of pregnancy (Time 1), depression was assessed using the Edinburgh Perinatal Depression Scale (EPDS) (at Time 1 and 6 months after childbirth, i.e., Time 2), parenting stress was assessed using the Parenting Stress Index—Short Form (PS-SF) (at Time 2) and the Strange Situation Procedure (SSP) at child’s 15 months of age (Time 3). Results: Free-autonomous maternal classification of attachment increases the likelihood of secure child classification in her offspring, while decreases that of avoidance and ambivalence. Insecure maternal representation of attachment evaluated during pregnancy and higher levels of parenting stress at six months after childbirth was associated with higher rates of infant insecure attachment at 15 months. Conclusions: Our study validates the importance of considering maternal representations of attachment crucial in determining the quality of the caregiving environment, thereby the healthy development of children, despite the presence of other contextual risk.

The effects of childhood unpredictability and harshness on emotional control and relationship quality: A life history perspective

Being able to control oneself in emotionally upsetting situations is essential for good relationship functioning. According to life history theory, childhood exposure to harshness and unpredictability should forecast diminished emotional control and lower relationship quality. We examined this in three studies. In Studies 1 and 2, greater childhood unpredictability (frequent financial, residential, and familial changes), but not harshness (low SES), was associated with lower emotional control in adolescents (N = 1041) and adults (N = 327). These effects were stronger during the participants’ reproductive years. Moreover, in Study 2, greater childhood unpredictability was indirectly associated with lower relationship quality through lower emotional control. In study 3, we leveraged the Minnesota Longitudinal Study of Risk and Adaptation (N = 160). Greater early-life unpredictability (ages 0–4) prospectively predicted lower relationship quality at age 32 via lower emotional control at the same age. This relation was serially mediated by less supportive observed early maternal care (ages 1.5–3.5) and insecure attachment representations (ages 19 and 26). Early unpredictability also predicted greater observed emotional distress during conflict interactions with romantic partners (ages 19–36). These findings point to the role of emotional control in mediating the effects of unpredictable childhood environments on relationship functioning in adulthood.

Assessment of Attachment Representations in Basque Adolescents and their Relationship with Internalizing and Externalizing Problems

Research has shown a relationship between attachment style and psychosocial adjustment in adolescents. Whereas secure attachment is related to fewer internalizing and externalizing symptoms, the opposite is the case for the various insecure attachment styles. The aim of the two studies reported in this paper was to adapt and validate the CaMir-R (a self-report measure of attachment that has shown adequate psychometric properties) for use among Basque adolescents, and to analyse the relationship between attachment and internalizing and externalizing symptoms. In Study 1, the instrument was adapted using the back translation method and applied to a sample of 203 adolescents and young adults. Confirmatory factor analysis supported the theoretical dimensions of the scale, and its psychometric properties were found to be adequate. In Study 2 we obtained additional validity evidence by applying, in a sample of 786 adolescents and young adults, the attachment representations section of the CaMir-R alongside other measures of attachment and clinical symptoms. The results once again supported the dimensional structure of the instrument, and evidence of convergent validity was obtained based on correlations between CaMir-R scores and scores on the Inventory of Parent and Peer Attachment (IPPA). In addition, scores on the five dimensions of attachment representations (Security, Family concerns, Parental interference, Self-sufficiency and resentment of parents and Childhood trauma) were correlated with scores on other measures of internalizing and externalizing symptoms. Based on these results, we conclude that the Basque version of the CaMir-R is a valid instrument for assessing the quality of attachment representations among adolescents, and also that internalizing and externalizing problems are related to attachment style. We discuss the importance of attachment in relation to behaviour problems and clinical symptoms.

Maternal attachment representation, the risk of increased depressive symptoms and the influence on children’s mental health during the SARS-CoV-2-pandemic

The social distancing measures and the related closure of education institutions have confronted young families, in particular, with various challenges. Additional risk factors such as an insecure or even unresolved maternal attachment representation may affect mental health of mothers and their children in times of increased stress such as during the ongoing pandemic. We aimed to analyze the interplay between maternal attachment representation and mother’s and children’s mental health before and during the SARS-CoV-2-pandemic. 91 mothers completed a “SARS-CoV-2 pandemic survey” examining the pandemic-related stress of their families including their own depressive symptomology and their children’s mental health. Our mediation analysis demonstrates that the mothers’ depressive symptomology significantly and fully mediated the relationship between maternal attachment representations and children’s mental health during the pandemic. In contrast, the indirect effect of the maternal attachment representation on children’s mental health before the pandemic through the depressive symptoms experienced by the mothers before the pandemic did not reach significance alongside the total and direct effect. The quality of the maternal attachment representation, promoted by childhood maltreatment, seems to be one relevant risk factor for the mothers’ and children’s mental health during a stressful time like a pandemic. The risk for mothers to develop depressive symptoms in times of a pandemic is significantly influenced by their current representation of previous attachment experiences. In addition, the mental well-being of mothers showed a considerable influence on the children’s mental health during a pandemic. The results underline the necessity to consider unique needs of family members and to offer specific support in the current crisis focusing on attachment issues.

Attachment Representations in Children with and without Attention-Deficit/Hyperactivity Disorder (ADHD)

Attention-Deficit/Hyperactivity Disorder (ADHD) in children is associated with several adverse family characteristics, such as higher parenting stress, more conflicted parent–child relationships, lower parental competence, and higher levels of parental psychopathology. Hence, children with ADHD more often grow up under suboptimal circumstances, which may impact the development of their attachment representations. Here, we investigated whether children with ADHD have more insecure and disorganized attachment representations than their typically developing peers, and which factors could explain this association. We included 104 children between 4 and 11 years old, 74 with ADHD (without Conduct Disorder) and 30 typically developing control children. Children completed a state-of-the-art story stem task to assess their attachment representation, and we measured parents’ expressed emotion (as an index of parent–child relationship quality), parents’ perceived sense of competence, parental education levels, and parent-rated ODD symptoms of the child. We found that, after controlling for multiple comparisons, children with ADHD had less secure and more ambivalent and disorganized attachment representations relative to their typically developing peers. These group differences were independent of comorbid ODD and parental education levels. There were no group differences on avoidant attachment representations. Explorative analyses within the ADHD group showed that attachment representations were not related to parent–child relationship quality, perceived parenting competence, parental education levels, and comorbid ODD symptoms. We conclude that children with ADHD disproportionately often have attachment problems. Although this conclusion is important, treatment implications of this co-occurrence are yet unclear as research on ADHD and attachment is still in its infancy.

Patient’s and the Therapist’s Attachment Representations, Attachment to Therapists, and Self-Esteem-Change Through Psychotherapy

Objectives: The present naturalistic study aims to investigate the differential effects of the patient’s and the therapist’s attachment representations on the attachment to the therapist as perceived by the patient, and their impact on self-esteem-change through psychotherapy.Methods: Attachment variables of N = 573 patients as well as N = 16 therapists were assessed. Attachment representations were measured for therapists and patients via the Bielefelder Questionnaire for Client Attachment Exploration, the Relationship Specific Attachment to Therapist Scales and the Adult Attachment Interview. The patient’s attachment to therapists was evaluated and patients’ self-esteem was measured via the Frankfurter Selbstkonzeptskalen at the beginning and end of psychotherapy.Results: Although there were significant effects of the patient’s attachment representations on the perceived attachment to the therapist as well as between the perceived attachment to the therapist and the amount of self-esteem-change, the therapist’s attachment style had no significant influence on the perceived attachment to the therapist.Conclusion: Self-esteem-change through psychotherapy is influenced by the actually formed attachment relationship as perceived by the patient. The patient’s attachment representations but not the therapist’s attachment style contributes to the actual patient’s attachment to the therapist.