Addressing psychiatric and psychosocial issues related to children and adolescents
Attachment is an emotional bond that connects one person to another. This mutual connection does not have to be reciprocal or shared. The behavior of attachment was first studied by John Bowlby and later by Mary Ainsworth (Ainsworth et al., 1971). They studied the importance of a child's relationship with their primary caregiver and its effects on their emotional, social, and cognitive development.
An infant's attachment pattern is determined by the understanding of their caregiver's reliability as a source of comfort and safety. A primary caregiver represents a secure base from which an infant can confidently explore and to which they will naturally return to as a source of comfort and security. Ainsworth, a psychologist, devised an assessment technique called the Strange Situation Classification to investigate how attachments might vary between children. Ainsworth (1971) identified three main attachment styles: insecure avoidant (type A), secure (type B), and insecure ambivalent/resistant (type C). Her experiments suggested that these attachment styles were the result of early interactions with the caregiver and mother in these experiments. A fourth attachment style, known as disorganized, was later identified (Main & Solomon, 1990).
Psychology of Attachment Pattern
Psychology of attachment pattern originates from infants' universal need to seek proximity with their caregivers, especially under the conditions of stress and uncertainty. Attachment increases the chances of infants' survival as well. Bowlby (1982) originally focused on attachment because his clinical work identified parent–child relationships as influencing the development of challenging behaviors in childhood. Subsequently, scientists have sought to understand how insecure attachments may contribute to developing externalizing (e.g., aggression, delinquency) and internalizing (e.g., anxiety, depression) behaviors.
A cross-sectional study showed that children who had a strong bond with their caregiver, when separated, stayed calm with the belief that their caregiver would return (Goldsmith et al., 2004). However, children with poor attachment patterns would cry and show signs of distress even after they were reunited with their caregivers. It was observed that the quality of attachment with the caregiver can have long-lasting effects on the relationships between people, even into adulthood.
Parent–child relationships influence children's social and emotional development. Research on parent–child attachment showed that in the first year of life, all children form attachments to caregivers who provide them protection (Bowlby, 1982). The secure base phenomenon occurs when a child uses their parent as a haven during times of distress. Several investigators have examined the association between early sensitivity and adult attachment styles using retrospective reports. These studies generally reveal that adults who recall warm and loving relationships with their early attachment figures are more likely to rate themselves as secure in attachment. For example, Hazan and Shaver (1987) found that adults who classified themselves as secure were more likely to describe their early experiences with their parents as being affectionate and loving. Adults who classified themselves as insecure, in contrast, were more likely to describe their parents as cold or rejecting (Collins & Read, 1990).
Theorists have also explained many contextual factors that may impact the quality of the caregiving environment. Maternal depression, for example, interferes with the parent's ability to provide a supportive environment for the child. In a large population-based survey, individuals who reported that their parents had experienced depressive episodes when they were young were more insecure in their attachment orientation (Cummings et al., 1994; Mickleson et al., 1997). Similarly, Davila et al. (1997) found that young adults who were secure across two assessment waves were less likely than those who were not secure to report a history of family psychopathology, such as depression.
Moreover, the quality of the relationship between parents themselves may play a role in shaping the quality of parenting (Rholes et al., 1995). Parental divorce, father's absence, or high parental conflicts all have the potential to signal to the child that other people may not be available. These kinds of ideas have been emphasized most explicitly by attachment theorists inspired by life history perspectives on development (Belsky et al., 2010). Researchers have found that adults who indicate that their biological parents divorced are more likely to report insecure attachment styles (Mickleson et al., 1997). In addition, researchers have found that early contextual stressors (e.g., father's absence, low socioeconomic status) are related to self-report measures of insecure attachment styles in adulthood (Chisholm et al., 2005).
A major tenet of attachment theory is the competence hypothesis, which posits that the formation of a secure attachment in childhood prepares a child for other social challenges (e.g., finding a place in the peer group) and places a child on a more positive developmental trajectory. In addition, securely attached children develop positive expectations about others and a greater sense of self-efficacy, which in turn facilitates their social relationships. Children who are more securely attached form more positive relationships with peers, cooperate more with adults, and regulate their emotions more effectively. Insecurely attached children are more likely to have difficulties regulating emotions and interacting competently with peers, which may further contribute to anxiety (Weinfield et al., 2008).
Neurobiology of Attachment Pattern
Attachment neurobiology develops early, beginning in utero, and continues into early preschool years. This complex process involves the development of the hypothalamus-pituitary-adrenal (HPA) axis and reward system early on, followed by the development of the amygdala. By early adulthood, the medial prefrontal cortex (PFC) has matured. The development of the hypothalamus in the fetus depends on the maternal HPA axis. At birth, the hypothalamus is fully developed. The hypothalamus functions through the HPA axis to produce cortisol by the adrenal glands. Cortisol has a specific effect on the developing brain. In high doses, cortisol is highly neurotoxic and inhibits neuronal connections, whereas lower levels of cortisol induce neuronal development and growth through neuroplasticity (Vela, 2014).
Oxytocin and social interaction have been shown to decrease cortisol levels, demonstrating that even at this early stage, the physical connection between a mother and her infant has an important effect on brain development. Adults with insecure attachment show a hyper-reactive HPA axis and cortisol response to acute stress (Quirin et al., 2008). Therefore, neglect or abuse in the first few months of life can significantly impair the development of the hippocampus (Huot et al., 2002).
The amygdala matures at 6 to 7 months of age. With this development, the beginnings of fear and salience are seen, two important functions of the amygdala (Vela, 2014). Infants at this age will show stranger anxiety and protest separation from their mother. Reports show that the amygdala may serve as an emotional compass, without which one can feel lost, causing depression and anxiety over time (Swain, 2008).
The medial PFC begins development in the early neonatal stage and continues to evolve through pruning until the middle of the third decade of life. Although the role of the immature PFC in infants and children is unclear, the mature PFC is important in the process of emotional regulation. The proper development of the PFC likely depends on the functionality of earlier neurobiological developments. However, although the exact role of the PFC in the attachment process early in development remains unclear, it is clear that the PFC has an important role in modulating anxiety and depression, which may rely on a healthy neurobiological environment during early development (Lungwitz et al., 2014).
As we have a better understanding of the attachment neurocircuitry, we can see how this sensitive period of development, starting from in utero to the early preschool years, leads to neurobiological changes later in life, affecting emotional response, reward, and perceptual difficulties. Our understanding of neurobiology validates what psychoanalytic theory has always assumed—the significant importance of early development and the necessary process of each stage of development, building on earlier stages and experiences.
Implications of Attachment Patterns on Mental Health
Attachment patterns have a wide range of consequences for mental health. The National Institute on Drug Abuse has repeatedly mentioned that lack of attachment and nurturing by parents or caregivers is one of the main contributing factors for later substance use (Lander et al., 2013). The Adverse Childhood Experiences (ACEs) study revealed that children who have had four or more ACEs are 4.5 times more likely to develop depression, 14 times more likely to die by suicide, 11 times more likely to use substances intravenously, four times more likely to have begun intercourse by age 15, three times more likely to smoke and have lung disease as an adult, and twice as likely to develop liver disease (Oral et al., 2016). ACEs include emotional or physical abuse or neglect, sexual abuse, domestic violence, substance use and/or mental illness in the family, parental separation/divorce, and incarcerated parents (Oral et al., 2016).
Clinical Implications of Attachment Patterns
Clinically, it was found that through repeated positive experiences with a caregiver, infants develop a secure attachment to that person. They learn to trust other people. They have fewer extreme reactions to stress, explore independently, become better problem solvers, and form better relationships with others. Conversely, infants who have negative experiences with a caregiver are more likely to develop an insecure attachment behavior. Children with insecure avoidant behavior do not orientate to their attachment figure while investigating the environment. They are likely to have an insensitive caregiver. Children who have an insecure ambivalent attachment pattern may refuse to interact with others; exaggerate distress; and show anger, anxiety, or fear. They fail to develop feelings of security from the attachment figure. A disorganized attachment pattern is considered an extreme form of insecure attachment. Many infants who fall into the disorganized category have experienced maltreatment or have been traumatized by severe loss or abuse (Bailey, 2016; Behrens, 2016; Duschinsky & Solomon, 2017; Main & Solomon, 1990). Clinical implications of attachment patterns and percentages of their distribution are summarized in Table 1.
Clinical Features of Attachment Patterns in Children and Infants
The psychology of attachment behavior reveals that securely attached infants, with a strong bond with their caregivers, seem to explore new possibilities and have better executive functioning and social interactions. In contrast, children with insecure (avoidant and ambivalent) attachments, who had challenging interaction with their caregivers, struggle with building and maintaining relationships, and display emotional dysregulation when distressed. Children with disorganized behavior patterns exhibit signs of extreme disorientation in stressful situations under abused caregivers. These attachment behaviors are highly dependent on the neurobiology of the attachment pattern that starts developing before birth and continues to preschool.
- Ainsworth, M. D. S., Bell, S. M. & Stayton, D. J. (1971). Individual differences in strange situation behavior of one-year-olds. In Schaffer, H. R. (Ed.), The origins of human social relations (pp. 1–18). Academic Press.
- Bailey, N. (2016). Attachment styles, parenting styles and theory of mind: An exploration of their relationships with social deficits in autism spectrum disorder [Master's thesis]. https://open.uct.ac.za/handle/11427/24460
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Clinical Features of Attachment Patterns in Children and Infants
|Attachment Patterns, Percentagesa||Clinical Features|
|Insecure avoidant (type A), 15%|
Very independent of the attachment figure physically and emotionally.
Does not seek contact with the attachment figure when distressed.
The attachment figure may withdraw from helping the child/infant and is often unavailable during times of emotional distress.
|Secure (type B), 62%|
Feel confident that the attachment figure will be available to meet their needs.
Use attachment figure as a safe base to explore the environment and seek attachment figure in distress.
Develop a secure attachment when the caregiver is sensitive to their signals.
|Insecure/ambivalent (type C), 23%|
Adopt an ambivalent behavioral style toward the attachment figure.
Commonly exhibit clingy and dependent behavior but will be rejecting of the attachment figure when engaged in interaction.
Difficult to soothe and not comforted by interaction with the attachment figure when distressed.
|Disorganized behavior pattern, 12.7%|
Lack an organized pattern in their behaviors or have strategies that repeatedly break down.
When stressed, in the presence of their caregiver, these infants appear disorganized, displaying unusual behaviors, such as approaching the caregiver with their head averted or strange postures.
Stressful situations involving reorganization of the family, such as family moves or the birth of another child, may also temporarily disorganize attachment patterns in an infant–caregiver relationship.