What is attachment theory used for?

Attachment theory^{1, 2, 3} is amongst the most popular theories of child development and has received much attention from psychologists and researchers across the world for the last 50 years. In addition, it has captured the interests of doctors, teachers, lawyers, politicians and policy-makers, and is the subject of several commercially available books and training packages for social workers and foster carers. Such popularity implies that it is perceived by many to be of great importance and utility to understanding people and their behaviour in different contexts – but, why?

Remarkably, the original inspiration for this theory came from observations of the behaviour of baby greylag geese⁴. These creatures showed a clear tendency to follow whomever was the first large moving object they encountered within the initial few hours of life, whether that be their mother goose or indeed the researcher Konrad Lorenz himself!  Crucially, this was understood as a way of promoting their overall survival in the world, as such behaviour ensured that the baby geese were always in close proximity to someone who could protect them, should they encounter harm in their new environment. Later, John Bowlby, the founding father of attachment theory, noticed that when alarmed, unwell or following a separation, children would also seek proximity to a familiar caregiver. Bowlby theorised that, likewise, this behavioural response, which he called the attachment system, had developed as a strategy for ensuring the survival of human babies.

Influenced by Bowlby, Mary Ainsworth⁵ identified patterns in the behaviours that children use to communicate distress and their need for protection and comfort. The Ainsworth patterns of infant behaviour were found to correspond to observations of how children behaved at home: infants who had experienced sensitive and responsive care were more likely to communicate feelings of distress and accept comfort following a brief separation; whereas infants who had experienced insensitive or frightening care were less likely to be able to use the caregiver as a safe haven when alarmed. The Ainsworth patterns of attachment behaviour have been found all over the world⁶ and studies show notable, though not full, continuity between infant attachment patterns and adult patterns of emotion regulation and interpersonal interaction. Researchers have also found that the kinds of behaviours caregivers show are influenced in important ways by the caregiver’s own childhood experiences, mental health, and current environment and availability of support.

The idea of attachment highlights the importance of early relationships for our emotional life and adult relationships. It also highlights how relationships are shaped by the environments we have experienced in the past and present. These factors may contribute to the appeal of the theory to many areas of public sector work. So, how have various professionals in the real world used knowledge and research about attachment theory?

Historically, attachment theory has been used to emphasise to policy-makers the importance of contact between caregivers and their children in the first few hours, months and years of life. It was a key driver behind the implementation of mother and baby units in healthcare services, and other childcare policies regarding hospitalised or institutionalised children or those in poor quality daycare⁷. Some more recent applications for health and social care policy have attracted criticism for being used in pursuit of politicising within a welfare state agenda. For example, in Early Intervention: Good Parents, Great Kids, Better Citizens, Graham Allen and MP Iain Duncan Smith argue that ‘focusing on the first three years of children’s lives’ means ‘reducing dependence on the state’ among the citizens who will be produced’ (2009: 97).

Psychologists and other healthcare practitioners pay close attention to the behaviour of children and their parents during clinical assessments. Consideration of how emotions and difficulties are managed within the family can reveal information about parent-child relationships; however it is not possible to draw definitive conclusions about specific attachment patterns through these unstructured observations. Practitioners with advanced training in validated assessments of attachment may use these within clinical practice, but the time and financial resources needed for the training and interpretation of results typically make this unfeasible. Instead, practitioners are required to select and integrate their knowledge of theory and research into practice-knowledge that is useful for the clinical tasks of diagnosis, formulation and treatment selection. Little is known currently about how practitioners do this and how helpful attachment ideas are for routine clinical practice.

Some social welfare professionals have been encouraged through training and policy documents to use tools to identify unusual ways in which children express emotional distress or need for comfort. While this can be helpful for gathering assessment information, some research and policy documents have suggested the information offers child protection professionals a proxy or screening tool for assessments of child maltreatment and risk. A recent consensus statement published by over 40 experts in the field cautions practitioners strongly against using such knowledge in this way⁸.

Meanwhile in academia, researchers have continued to use specialised assessments of caregiving behaviour and child attachment patterns to help answer other important questions. E.g. what aspects of caregiving behaviour are most important for healthy development? How do attachment experiences interact with children’s genetic makeup? And, what are the implications of poor quality attachment relationships for later life mental and physical health? Answering these questions has identified parental sensitivity as a key treatment target with the potential to dramatically improve the health and wellbeing of children, even those with other genetic vulnerabilities. In fact, studies show that children at the highest risk of adverse consequences from their childrearing experiences are able to benefit most from supportive parenting interventions⁹!

Clinicians and researchers are together developing and testing interventions to support parents, typically using video-feedback.  This approach is now the flagship recommendation of the National Institute of Clinical Excellence, alongside child behaviour training and parent-child psychotherapy. The treatment options outlined in the 2015 guidance¹⁰ should be used in favour of previous controversial and poorly-evidenced approaches known as ‘attachment therapies’ including ‘holding therapy’ and ‘re-parenting’. These approaches are not regarded as having any basis in attachment theory and research – besides using the word ‘attachment’ in the title. They have used combinations of restraint and enforced obedience even against all attempts of resistance from the child, sometimes leading to significant harm¹¹.

Overall, applications of attachment theory have been significant and varied. Attachment theory has influenced large-scale public health and policy change and the development of effective therapeutic interventions. However there also appear to have been misapplications of attachment ideas and assessments. We do not yet know whether cost and time effective assessments of attachment can be validated for use with at-risk families, and whether these show greater predictive significance than alternative forms of assessment. This would be strong evidence that attachment is an important specific component in effective assessment, yet, in the meantime, it appears that attachment remains an important heuristic used by clinicians and social welfare practitioners, even if there can be haziness in how the concepts are used.

References

1. Bowlby, J. (1969/1982). Attachment, Volume 1 (Attachment and Loss). London: Pimlico.
2. Bowlby, J. (1973). Separation: Anxiety and Anger, Volume 2 (Attachment and Loss). London: Pimlico.
3. Bowlby, J. (1980). Loss, Volume 3 (Attachment and Loss). London: Pimlico.
4. Lorenz, K. (1935). Der Kumpan in der Umwelt des Vogels. Der Artgenosse als auslösendes Moment sozialer Verhaltensweisen.Journal für Ornithologie, 83, 137–215, 289–413.
5. Ainsworth, M.D.S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns of Attachment: A Psychological Study of the Strange Situation, Hillsdale, NJ: Lawrence Erlbaum.
6. van IJzendoorn, M.H. & Sagi, A. (1999). Cross-cultural patterns of attachment: universal and contextual dimensions. In Handbook of Attachment: Theory, Research, and Clinical Applications (2^nd Ed), Edited by: J. Cassidy & P. R. Shaver, Guilford Press, New York, 880–905.
7. Rutter, M. (2008). Implications of attachment theory and research for child care policies. In Handbook of Attachment: Theory, Research, and Clinical Applications (2^nd Ed), Edited by: J. Cassidy & P. R. Shaver, Guilford Press, New York, 958-974.
8. Granqvist, P., Sroufe, A.,L., Dozier, M., Hesse, E., Steele, M. et al. (2017). Disorganised attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers. Attachment and Human Development, doi: https://doi.org/10.17863/CAM.11313
9. van IJzendoorn, M.H. & Bakermans-Kranenburg, M.J. (2001). Differential susceptibility to rearing environment depending on dopamine-related genes: New evidence and a meta-analysis. Development and Psychopathology, 23, 39-52, doi:10.1017/S0954579410000635
10. National Institute for Health and Care Excellence (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care. NICE Guideline [NG26]. https://www.nice.org.uk/guidance/ng26
11. Zeanah, C.H., Chesher, T. & Boris, N.W (2016). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 55(11), 990-1003.

This is an independent article and the views are not necessarily those of ACAMH.