Attachment Theory: Mother and Child, is it that simple?

 Attachment Theory (AT) leans towards the notion that there is an inherent glue that unites a mother and a child, but there are concerns that this notion oversimplifies the complexity of birthing and rearing children (Franzblau, 1999). AT proposes that adults have the power to protect and provide security for their children by developing a secure attachment between the child and primary caregiver which forms the basis of all their future development and interactions. AT is more complex than it was originally perceived to be with the emergence of Modern Attachment Theory, which is based on psycho-biological findings which show the impact that early transaction between infant and primary caregiver has on the development of the psychic structures of the brain. The strength of the attachment that is developed aids in the maturation of brain systems, which involves affect and self-regulation, thus impacting the child’s cognitive and behavioural domains (Holmes, 2017). 

The background and emergence of AT is explored whilst visiting the path taken by John Bowlby (Bowlby) and Mary Salter Ainsworth (Ainsworth). AT emerged from the era of World War II when broken families and orphans were rife. The main assumptions of AT are the development of emotional and intimate bonds between the primary caregiver and child, the influence of caregivers on the personality development of the child, the ‘internal working model’ of the child, and, finally, that, at no point in life, is positive change no longer possible for the child. An understanding of the Strange Situation Procedure by Ainsworth is explored to gain an understanding of its influence in the development of AT and its integration into the theory. 

The attachment styles include secure attachment, insecure-avoidant attachment, insecure-ambivalent attachment and disorganised attachment, all of which will be explored and applied to three case studies to gain an understanding of the risk and protective factors of developing psychopathology later in life. The case study of “Aaron” explores the story of a teenager who suffered from stuttering and depression. These disorders are explained to be rooted in the attachment he shared with his mother. This case study illustrates how attachment styles can impact personality development and susceptibility to psychopathology later in life. 

The case study of “Matilde” explores the story of a young girl who grew up in an environment where she was sexually abused and emotionally neglected. This resulted in her developing Borderline Personality Disorder (BPD) in early adulthood. The development of this personality disorder is explained in relation to her insecure attachment with her parents. The case study of “Mitchell”, explores the story of a young boy who suffers the loss of his mother at the age of three. The loss of his primary caregiver caused him to suffer from Post-Traumatic Stress Disorder (PTSD) and separation anxiety which is further explained in relation to AT.

In order gain an in-depth understanding of AT it is important to go back to the developmental history of the theory. Bretherton (1992) states that AT is based on work done by both Bowlby and Ainsworth. The author states that Bowlby studied Developmental Psychology and went on to work at a school for maladjusted children. Bretherton notes that it was Bowlby’s experiences at this school, whilst treating two children, that would spark his interest and inform the path taken in his professional life. The first child he treated at the school was a very distant and affectionless teenager who had previously been expelled from his school for stealing, Bowlby would come to learn that this teenager had no mother figure in his life. The second child was about 8 years old and suffered with anxiety and would spend his days following Bowlby around like a shadow. The experience of these two boys made Bowlby realise the effect that early family relationships have on the development of an individual’s personality.

Bretherton (1992) indicates that Bowlby went on to pursue his career as a child psychiatrist. When World War II broke out Bowlby served in the military and used this opportunity to conduct further research. During this time, Bowlby’s career was influenced further by Melanie Klein (Klein), a psychoanalyst who was also known for her work in child analysis and who was pivotal in the development of Object Relations Theory. During his training at the British Psychoanalytic Institute Bowlby noticed that much clinical work was carried out using the Kleinian orientation which held that children’s motivation was due to the fantasies they generated from an inner conflict between libidinal and aggressive drives rather than about actual events which took place in their lives. Bretherton remarks that Klein criticised Bowlby’s work stating that his focus on patterns of family interactions was not relevant. This frustrated Bowlby and so he decided to shift the focus of his research onto the mother-child separation as this was a clear cut event which could not be disputed. 

Sadock, Sadock and Ruiz (2015) states that Bowlby proposed that there was an evolutionary basis for attachment behaviour as adults are programmed to protect their young; this premise formed a critical part of AT. The authors advise that ethological studies confirm that animals and nonhuman primates display inborn, instinctual tendencies of attachment behaviour, also known as imprinting. An example of imprinting is that certain stimuli can elicit behavioural patterns in the first hours of life so that the offspring becomes attached to its mother. Sadock et al. states that imprinting is seen to be a critical stage in the development of the young and the same is said to be true for human infants but this stage often takes place over a longer period such as a few years rather than just a few hours. 

Bretherton (1992) indicates a further contributor to AT was Mary Ainsworth. The author states that Ainsworth was a developmental psychologist and best known for her Strange Situation assessment. She graduated from the University of Toronto just before World War II and was six years younger than Bowlby. Bretherton explains that part of Ainsworth’s background was the work she did with William Blatz (Blatz), a German-Canadian developmental psychologist who introduced her to the Security Theory which he had created. The author explains the main concept of Security Theory is that infants and young children need to form a secure bond with, or dependence on, their parents before being able to go into unfamiliar situations. 

Bowlby and Ainsworth both served time as military officers during World War II, which was something they had in common (Bretherton, 1992). Their time served in the war was instrumental in shaping both their careers as they were involved in research and training programs, and were exposed to the effects of children separated and orphaned from their families as a result of the war. Bretherton explained they would first come to meet in London when Ainsworth worked under Bowlby whilst researching the effects of an infant’s separation from its mother in early childhood and the impact this has on personality development. Bowlby and Ainsworth contributed to AT, which stated that, for a child to grow up with their mental health intact, the young child should have a continuous relationship, that is warm and intimate, with their mother (or primary caregiver) in which they feel satisfied and have enjoyment (Bretherton, 1992).  Sadock et al. (2015) explains this theory was tested and proven by Harry Harlow (Harlow), an American psychologist who is known for his controversial and cruel experiments with rhesus monkeys. The author explains that Harlow was also seen to have contributed to the development of AT by providing empirical evidence using these studies which involved observing the emotional and behavioural effects of isolating the monkeys from birth so that they were unable to form attachments. Sadock et al explains these monkeys became withdrawn, they were unable to connect with peers, unable to mate and were incapable of caring for their babies, thus confirming the importance of attachment in the early phase of life. Steele (2003), explains the four basic assumptions of AT as developed by Bowlby emerged. The first assumption is that the emotional and intimate bonds formed between a primary caregiver and the child have a primary status and biological function, this relates to the emotional and intimate bond formed between a primary caregiver and the child. Bowlby maintained that our survival as individuals was dependent upon our ability to maintain and establish ties to others. The second assumption is that the treatment a child receives from their caregiver has a strong influence on their development and personality functioning. The theory is that healthy psychic development is found, not only in the number of attuned or misattuned interactions, but also in the sequence of either connection or disconnection, and how this is repaired and restored in subsequent interactions. The third assumption is the internal working model whereby Bowlby states that the meaning of our experiences is encrypted into the way we guide our expectations and behaviour. This model not only influences expectation and beliefs about others but can also elicit behaviours in response to others. The fourth assumption is that there is a potential for change in attachment patterns Bowlby asserts that there is no point in life at which positive change is no longer possible.  

AT reasons that observing how a young child behaves towards his mother in her presence, and particularly in her absence, can contribute to understanding personality development (Lee, 2003). Cherry (2019), states that, according to Bowlby, there are four distinguishing characteristics of attachment between parent and child. Firstly ‘proximity maintenance’, which relates to the desire to be close to the people we are attached to. Secondly, ‘safe haven’, which relates to the child returning to the attachment figure for comfort in the face of fear or threat. Thirdly, ‘secure base’, where the attachment figure provides a secure base (security) so that the child feels able to explore the surrounding environment. Finally, ‘separation distress’ which refers to the anxiety that the child experiences when the attachment figure is no longer there. Ainsworth was instrumental in developing the Strange Situation Procedure which contributed greatly to the concept of a secure base, exploratory behaviour and maternal sensitivity. Ainsworth attributes part of the credit to Blatz as she drew on her experiences with him, and his development of the security theory, in developing her Strange Situation Procedure (van Rosmalen, 2015). This procedure was revolutionary in its time. The Strange Situation Procedure was a laboratory procedure which measured the security of attachment by observing how children react to a series of three-minute separations from their parents. Ainsworth found that securely-attached children became visibly upset but were easily comforted on the reunion with their parent and then quickly returned to exploratory play.  In contrast, insecure-avoidant children became emotionally withdrawn, during both the separation from, and reunion with, their parent, whilst insecure-disorganised children responded by using strange self-soothing mechanisms such as dissociation (van Rosmalen, 2015). 

Cherry (2019) explains the four attachment styles (secure attachment, insecure-avoidant attachment, insecure-ambivalent attachment and disorganised attachment) as developed by Bowlby and Ainsworth: 1) Children with a ‘secure attachment style’ are able to separate from their parents, they look for comfort from their parents when afraid, welcome their parents with positive emotions upon return and prefer to be with parents as opposed to strangers. As adults they are able to have trusting and lasting relationship, their self-esteem is intact and they are comfortable in intimate relationships and have stable social relationships. 2) Children with ‘insecure-avoidant attachment style’ may avoid their parents and not seek them out for comfort. They may also not show preference for their parents over strangers. As adults they may have issues with intimacy and not invest much emotion into romantic or social relationships. 3) Children with ‘insecure-ambivalent attachment’ are often wary of strangers, they become very distressed when their parents leave but then don’t appear comforted by their parents’ return. As adults they are reluctant to become close to others, they are often insecure and become very emotionally distraught when relationships end. 4) Children with ‘disorganised attachment’ often show a mixture of avoidant and resistant behaviour, and they can come across as confused, apprehensive and distant. As adults they are at a greater likelihood of developing mental health issues.

Field (1996) criticised the Strange Situation Procedure, claiming it has limitations as it is largely based on the child’s reaction to a stressful event rather than a non-stressful event. He goes on to say that for this to be objective it needs to focus on more than just the departure and reuniting of the child from the parent as these are not the only factors that determine attachment. Further to this, Field argues that attachment is not only characterised by certain behaviours (like crying) as children may have physiological changes in behaviour that go unnoticed and therefore it is incorrect that only blatant behaviours (such as crying) should be measured as part of the attachment. Also, Field pointed out that children can have attachments to other family members (father/sibling/grandparents) and this was not accounted for in the Strange Situation research. AT has been the source of controversy amongst various groups and it is not surprising that supporters of the Feminist movement were drawn to this theory as they aim to promote women’s rights and interests. Their interest in AT came from the assumption that the theory addresses one of women’s major roles, the mother and child role. Birns (2015) remarks the history of childhood and mothering is of importance here as, historically, mothers have been blamed for the outcome and/or behaviours of their children. An example of this is in the 1950s where theorists believed that schizophrenic children contracted the disorder due to the ‘mother’s behaviour’ which in turn caused the illness. Birns states this was eventually proven to be incorrect when research studies questioned how this could be true if, in a family of four children, only one had schizophrenia. The author states it was then that factors such as personality, genetics and environment were also considered when diagnosing mental illness. The supporters of the Feminist movement criticised this idealised version of the earliest attachment and the idea that the woman is the primary caregiver and carries all the responsibility of protecting the unborn and developing child (Franzblau, 1999). They believed that the responsibility has been atomized and reduced to its narrowest frame of reference, which is those families that are intact and which consist only of biological parents. Franzblau (1999) argued that this is based on the assumption that all children are consummated in the bliss of heterosexual love and that mothering is a natural outcome for each woman. The author also strongly argued that it was this ideology that caused the woman to be shunned and ostracized in the communities over many years for not fitting into these expected norms outlined by society and endorsed by theories such as AT. 

Birns (2015), endorses the arguments outlined above by saying that Bowlby fails to mention and acknowledge the “other-than-mother” factors present which also influence child development. He argues that Bowlby’s focus was merely on the maternal care or lack thereof and that part of his research involved war orphans with no allowance made for the fact that these children were socially deprived and were in sterile, overcrowded environments all of which could have contributed to the depression and grief these children suffered. Birns asserts it was not merely the loss of their primary caregiver or lack of maternal attachment alone. 

Birns (2015) points out that AT is rooted in psychoanalytic theory, which places Freud’s ideas at this time as pivotal. Freud was seen to be scientifically credible as he was a psychiatrist treating patients with psychopathology. Birns states the supporters of the Feminist movement noted that, historically, women have had authorities, usually men, instructing them on how to raise children, and this went as far as receiving instructions on child-rearing from their ministers and later from their paediatricians. The author states that although Freud did not instruct women how to raise children, he provided a theory which was based on the importance of childhood and the critical role of the mother during this period. He stated that the mother is the first and primary “object” who either gratified the child or did not. Freud also states that it was this relationship that was so unique that it laid down the basis that endured for a lifetime as the first and strongest love object which would serve as a prototype for all love relationships going forward in life. Birns states that feminists argue that there are more factors than just the relationship between mother and child that influence the mental health of children. He notes that Freud’s work influenced Bowlby and this impacted the way he viewed children in institutions. He states that Bowlby viewed the deprivation of the mother as being of paramount importance whilst minimising the deficits occurring in other aspects of the child’s life. Birns points out that it can be argued that children who were housed in institutions and were not exposed to a nuclear family with a mother figure did lack maternal care and sensitivity. He notes that Bowlby failed to prove that this maternal care could only be provided by a mother in a nuclear family, when in fact there may be other ways a child can receive this level of care.

Although these arguments made by the supporters of the Feminist movement raise important points, the development of AT has expanded its original scientific foundation and its application to clinical work over the past decade making it more relevant than ever. Schore and Schore (2007) acknowledges that Bowlby’s original theory was developed during a time when the emphasis was on behaviourism which then gave way to a dominance of cognition and an emphasis on reflective capacities and attachment narratives. He states that AT may come across as deceptively simple at first as it posits that the real relationship of our early stages of life shapes our basic survival functions in that, for the rest of our lives, our attachment processes lie at the core of our human experience. Schore and Schore, state that, as a result of intense research over the past 15 years, Bowlby’s core ideas have been further explained in a more complex and clinically relevant model namely Modern AT. This model includes recent advances in neurobiology that have assisted in the expansion of the theory which uses interdisciplinary data to propose that attachment communications are critical to the development of the neurobiological systems that process emotion, modulation of stress and self-regulation in the structural right brain. It has been argued by Holmes (2001) that “…individual development arises out of the relationship between the brain/mind/body of both the infant and caregiver held within a culture and environment that supports or threatens it”   (p. 10). Schore and Schore assert that this supports the theory that the attachment experience shapes the early organisation of the right brain which is the neurobiological core of the human unconscious. The author also states that it explains that unconscious interactive regulation has a central role in establishing attachment relationships which have lifelong implications for the development of the self. 

Supporting Bowlby’s theory of the importance of early attachment, Beebe and Lachmann (2014) more recently conducted research, namely “microanalysis”, whereby face to face (facial mirroring) communication is analysed in split-second intervals to find the origins of communication disturbances in infancy. They note that these interactions form part of the child’s schemas and determine if the child will have a secure or disorganised attachment as they move from childhood into adulthood. They explain that “attunement” as displayed in the ‘microanalysis experiment’ enables the infant to capture the quality of another’s inner feeling state. This interaction is powerful as the child looks to see if the inner feelings they experience are shared by the caregiver. This interaction can contribute to attachment security and the capacity for intimacy.   

This sentiment is confirmed by Schore and Schore (2007), “The essential task of the first year of human life is the creation of a secure attachment bond of emotional communication between the infant and the primary caregiver” (p.11). Further, he explains that to enter into this communication, the primary caregiver must be psychobiologically attuned to the slightest shift in the infant’s internal states of central and autonomic arousal. In this process of attunement, the mother will engage and disengage with the infant. Whilst disengaged she allows the child to ‘recover’ and then attends to the child’s needs by reengaging. It is during this process that the interaction becomes synchronised. This regulatory interaction creates a state of positive arousal and interactive repair which controls states of negative arousal which are important building blocks of attachment and its associated emotions. This process also aids in providing resilience in stressful or novel situations which forms part of attachment security. Schore and Schore advise that these events of attunement, misattunement, and re-attunement in an infant are critical in them becoming a person who has achieved ‘psychological birth’. This sequence of events forms the core of the infant’s self. They advise that although their emotional state is initially regulated by others, as they grow they increasingly become self-regulated as a result of their neurophysiological development.  Fonagy and Target (2005) attempt to finalise the debate of how critical attachment is for infants, by stating that the research shows that the attachment relationship is a major organiser of brain development and, therefore, its importance goes far beyond the provision of feeling safe and secure. 

In addition to the attachment bond another important factor to consider is the biological and psychological characteristics of individuals, their families and their environments which contribute to the development of mental health conditions. Pellegrini (1990) advises that the research agendas of epidemiologists and psychologists have been reshaped by the concepts of risk and protective factors such as stress, vulnerability and resilience to developing psychopathology. He assert that these concepts focus on the origins and course of psychopathology, and also focus on the individual’s characteristics, environments and their interactions therein during their lifespan. Pellegrini states that some of the risk factors that have been identified as being associated with the development of mental health issues include maladaptation in childhood, exposure to psychopathology in their parents, low socioeconomic status, low IQ, large family size, adverse life events, marital issues, divorce, parent-child relationship difficulties, lack of social support, social isolation, difficult temperament, prenatal and perinatal trauma, and genetics. The author advises that many of the protective factors are all of the items mentioned above but in reverse; for example, a protective factor would be a stable family environment (as opposed to divorce). Pellegrini points out that the single variable that, through its presence or absence, accounts for vulnerability or resilience across the lifespan, is family harmony. This then confirms that secure attachment between child and primary caregiver is a protective factor when it comes to developing psychopathology as an adult. The information provided above (AT, risk and protective factors of developing psychopathology) will be applied in the following three case studies of Aaron, Matilde and Mitchell. The first case study looks at how attachment is relevant in the adolescent phase of the child’s life and how an insecure attachment poses a risk to its mental health. Lajos (2012) presents a case study of a 13-year-old boy (Aaron) who was referred to speech therapy at three years old for stuttering. During his early period of diagnosis, Aaron presented with bedwetting, struggling with emotional problems, and moody and sad behaviour for no apparent reason. Aaron also became irritable and would withdraw from social situations. He lost interest in school and was thinking about committing suicide. Interviews were conducted with Aaron and collateral was collected from his mother and grandparents. 

The psychologist also performed various assessments on Aaron. Aaron was requested to do a mother-child drawing; this task is used to explore the characteristics of the relationship between a mother and her child. In this picture, Aaron drew a mother and child standing facing each other but they are not able to touch each other even though their arms are fully stretched outwards. Lajos (2012) explains that the diagnostic process concluded that Aaron had been separated from his mother when his young brother was born, and then again when he went to nursery school where he did not fit in. It was then at 3 years old that he began to stutter and at 4 years old he presented with bedwetting. These symptoms were seen to be a signal of his anxiety due to the early separation. The picture he drew showing himself being unable to reach his mother was also an indication that he never felt securely attached to her, thus putting him at risk of developing mental health issues. It seems that as he grew into his adolescent years he felt as though he never fitted into social or school groups. He was lonely (risk factor) and was bullied (risk factor) and teased by the other children which made him angry. His mother also had a change in her employment which resulted in her spending more time away from home. It was soon after this that Aaron became depressed and started to have suicidal thoughts.

Various theories can explain depression in adolescents but the explanation of insecure attachment in the case of Aaron is very relevant in the application of this case. Ewing, Krauthamer, Levy, Scott and Diamond (2018) confirm that insecure attachment in adolescence often translates into poorer developmental outcomes, which then results in a higher risk of the development of depression and suicidality. Bretherton (1992), explains that secure attachment in babies/children correlated significantly with maternal sensitivity, whilst babies/children with less sensitive mothers were more likely to be classified as insecure attachment. This would apply to the case of Aaron where he experienced periods of separation from his mother from an early age, with this emotional event manifesting at the age of 3 years old with his bedwetting. The insecure attachment experienced by Aaron may also have caused him to turn his anger and rejection inward, resulting in depression and suicidal thoughts. Chen (2019) states that there are attachment styles that can be linked to adolescent depression. He comments that children who have insecure attachment (risk factor) are more likely to experience the world to be scary and unpredictable. This results in the child not feeling safe to explore thus resulting in them experiencing feelings of helplessness and putting them at a higher risk of developing depression. 

Sroufe, Levy, Carlson and Egeland (1999) state that the earliest attachment relationships (risk/protective factor) are seen as vital as it is the first experience of emotional closeness that the child experiences and this forms the prototypes for how close relationships are formed throughout life. This can be related to the case of Aaron whereby he expresses that he was unable to fit in socially at school and felt as though he never belonged. Aaron was first referred to therapy for his stutter, and so it is relevant to understand the role of separation in the etiology of stuttering. Lajos (2012) explain that research shows that a high percentage of children who develop stutters were separated from their mothers before the onset of stuttering. He then states that historically, there has been much research which concluded that stuttering can be a defensive reaction to the trauma of a child’s separation from his mother and that it could also be explained by the child experiencing separation anxiety.

Ainsworth (1991) also provides a further perspective whereby she explains that as children develop into adolescents there are intervals where they no longer see their parents as attachment figures, which can explain why adolescents are commonly said to appear emotionally isolated at this stage of development. Markiewicz, Doyle and Brendgen (2001) explain that attachment is still an important factor in adolescents as three characteristics distinguish attachment from other bonds and relationships, which are particularly relevant to the adolescent years. Firstly, proximity seeking, which means that the child will try to remain within a protective range from his parent and will reduce this range when the child feels threatened. Secondly, secure base effect, which is the presence of an attachment figure that gives the child a sense of security, which enables the child to be confident and to explore. Thirdly, separation protest which is the continued accessibility to the attachment figure as they protest to ward off separation. The second case study looks at how maltreatment poses as a risk factor to children when understanding the developmental implications it has on its victims. Capaldo and Perrella (2018) present a case study of a 14-year-old girl named Matilde to demonstrate and gain an understanding of how the maltreatment of any nature affects the psycho-affective and cognitive development of children and how it influences their ability to form healthy relationships. Matilde was a victim of sexual abuse (risk factor) and reports feeling different from other children her age. She says she grew up but is not sure how this happened as she had no-one to take care of her. She mentioned that she waited all day for her mother to come home but often her mother stayed away for days. Her father was never home and when he was, he always had a full glass of wine and preferred to be left alone. Matilde recalled that her father often became irritated and violent (risk factor) and so she kept away from him. She recalls being alone (risk factor) and having to learn to do things on her own too soon. She attended school but had issues with the teachers and her classmates disturbed her as they were not like her. She made one friend called Flavia and they spent most of their time together. Matilde explained that she felt very attached to Flavia. They called and saw each other daily and Matilde felt Flavia was the only one for her and she wanted Flavia to feel the same way about her, but unfortunately, it was not like that.

This made Matilde feel sad and bad so she would invent reasons to call Flavia to find out where she was and what she was doing. She was afraid to be the “strange and abandoned Matlide again” (Capaldo & Perrella, 2018, p. 9) and she did not want Flavia to leave her, and this made her feel sad and angry. The only way she felt she could help herself was to lock herself in the bathroom and hurt herself repeatedly, which made her feel calm and peaceful. Matilde said she could not understand why her family was such a disaster (risk factor), she constantly felt different from others and did not understand why she felt alone and angry, and her thoughts always took her to the fact that she had a mother who was not there for her and a father that was violent and mostly drunk.   

Capaldo and Parrella (2018) propose that, based on their clinical observations, Matilde is presenting with the symptoms of BPD. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) states that BPD is “a pervasive pattern of instability of interpersonal relationship, self-image and affects, and marked impulsivity, beginning by early adulthood and present in a variety of contexts…” (American Psychiatric Association, 2013, p. 663). Capaldo and Parella state that this disorder results in behaviours including self-harm, chronic feelings of emptiness and uselessness, manipulative tendencies, fears of abandonment, compulsion, and problems with impulse control. They advise that the symptoms described by Matilde fluctuate due to her intense state of pain, anger, emptiness and loneliness. The impulsivity translates into self-directed destruction and behaviour related to verbal outbursts and altered relational models. The experiences Matilde has relayed in the case study have created such disturbance and discomfort to her that she has admitted it has caused her to carry out repeated acts of self-injury. AT has a leading position in understanding the mental health and well-being of a child and the implications it can have for their psychological development. 

Children (Matilde) exposed to abusive styles of parenting (risk factor) are more pre-disposed to developing an insecure or disorganised style of attachment (Golds, de Kruiff, & MacBeth, 2019). Insecure attachment is associated with the development of psychopathologies, in particular, research shows it is closely related to the development of personality disorders, again demonstrated in the case study of Matilde developing BPD (Capaldo & Perrella, 2018). Capaldo and Perrella (2018) state that if we attempt to understand this in the case of Matilde, it is evident that the combination of attachment disturbance and personality disorder is relevant. The case study shows that Matilde is maltreated by her primary caregivers as she expresses that she has been a victim of sexual abuse and her childhood was mainly characterised by neglect, violence and loneliness, and, therefore, her attachment cannot be described as secure. Matilde shows that she has impulsivity which mainly results in her repeated self-harm. This impulsivity is common in BPD functioning as in the case of Matilde who suffers from a strong negative effect which she is unable to manage. To cope with this, Matilde channels this destructive behaviour towards herself in self-harming behaviours. Liebernam, van Horn and Ippen (2005) advise that in contrast to the experience of Matilde, a protective factor against the development of psychopathology is maternal warmth. They note that this has been identified as playing a role in the child’s ability to adapt emotionally under adverse situations and shows characteristics of acceptance, support, positive affect and low parental harshness towards a child. They advise that these children showed fewer externalising problems when their mothers were more attuned to their needs. The third case study looks at the risk factor and impact that the loss of a mother can have on the mental health of a child. 

Zelenko and Benham (2002) present the case of Mitchell, a three-year-old boy, who is brought to the clinic by his Aunt (Mayra). Mitchell’s mood is unstable, sad and he has frequent tantrums and anger outbursts, and, at times, his anger results in him hurting others or himself. Mayra reports that Mitchell has night terrors, he is scared of the dark,is often triggered by the sound of sirens, is very clingy to Mayra and refuses to separate from her. Mitchell lost his Mother in a car accident, whilst he and his Dad were also in the car. His mother died on impact and when Mitchell woke up he saw his Mother’s dead body being removed from the car and put into an ambulance. Background history indicates that Mitchell’s family life before the accident was unstable. The father was diagnosed with bipolar disorder (risk factor) and he abused alcohol (risk factor) and thus struggled to remain employed. The family often lived in shelters and, in times like this, Mitchell would be separated (risk factor) from his mother and left with Mayra. Zelenko and Benham (2002) explain that, during play therapy, Mitchell would be drawn to the small cars, his play involved car crashes and people being killed, and he would re-enact it over and over again. Mitchell’s clinical presentation included the following symptoms: post-traumatic play, recurrent recollections of the accident, distress when exposed to reminders of the accident, problems with sleep, nightmares, and the development of aggressive behaviours and separation anxiety. 

Capaldo and Perrella (2018) state that these symptoms met with the criteria for PTSD (DSM-5). Holmes (2017), asserts that psychological difficulties in childhood are linked to maternal loss through death. Although all children suffer during maternal loss, Holmes states that research shows that bereaved children whose maternal care was previously adequate do not necessarily show behavioural and emotional difficulties, except that the loss of their mother leads to a major disruption in their lives. This can be seen in the case study of Mitchell whose maternal care was not adequate. Not only did he suffer the loss of his mother, but his family life and relationship with his mother before her death was reported to be unstable as he had periods of being separated from her whilst she was living in shelters and he was left with his Aunt, and his bipolar father abused alcohol. Zelenko and Benham (2018) explain that the loss of a primary caregiver (risk factor) in a traumatic event is a very difficult trauma for a young child to resolve. According to AT, when a child is exposed to a situation which evokes fear, they automatically turn to their primary caregiver for comfort. In the ideal situation, the caregiver (Mother) relieves the child’s (Mitchell’s) anxiety and provides the necessary protection and comfort. When the primary caregiver (Mother) is not available, the child (Mitchell) is left without a way to resolve or master the situation. This helplessness that is experienced is one of the factors that will be contributing to the PTSD that Mitchell is suffering. Zelenko and Benham suggest, based on AT, that, to treat Mitchell, the primary and urgent focus is the formation of a new attachment bond (protective factor). For Mitchell to form an attachment to Mayra will assist him in feeling secure and being able to go forward in therapy, thereby allowing him to reorganise his life and process the trauma and loss of his mother. Psychopathology is not straight forward, but is complex and not as simple as a sum of positive and negative experiences. However, early experiences do have special significance as it frames the way the child will interact with the environment thereafter (Sroufe et al.,1999). Schore and Schore (2007) state that AT has evolved over the years and modern attachment theory takes a developmental approach. They state that this includes regulation theory, updated internal object relations theory, contemporary relational theory and self-psychology, all of which are informed by infant research and neuroscience. Schore and Schore (2007) advise that the fundamental concept is: We understand any individual’s personal trajectory of emotional growth, including the development of his/her unconscious, to be facilitated or inhibited by the context of his/her family and culture. Attachment outcomes are thus the product of the interaction of both nature and nurture, the strengths and weaknesses of the individuals genetically encoded biological predispositions (temperament) and the early dyadic relationships with caregivers embedded within a particular social environment (culture). (p. 17).

‘Mother and child’ may seem initially as though it oversimplifies the complexity of birthing and rearing children, but, as explained, AT is a weave of complex threads. This theory, which emerged against a backdrop of World War II, begins with addressing the power of adults to protect and provide security for their children. When this power is abused, this fundamental biosocial contract between adults and children is ruptured. Bowlby bases the theory on the premise that children being exposed to various risk factors predisposes them to developing an insecure or disorganised style of attachment. These risk factors include abandonment, child maltreatment, substance abuse, sexual abuse, trauma (loss of caregiver), stress and poverty. Children raised in environments where there is a breakdown of the attachment and secure base will develop insecure and disorganised attachments, which leads to them feeling anxious and fearful towards their caregivers and others. As a result, these children are more likely to experience the world as scary and unpredictable which puts them at a higher risk of developing mental illness. AT confirms that the protective factors are maternal attachment, maternal care, attunement and sensitivity. The supporters of the feminist movement aimed to level the playing field by proposing that there are ‘other than mother’ factors that should be considered. Although valid points are raised, advances in Modern AT confirm that attachment communications are critical to the development of neurobiological systems which process emotion, and modulate stress and self-regulation in the structural right brain. These interactions between the brain, mind and body of both the infant and caregiver serve to either support or harm the child’s development of self. These schemas then become the foundation for all our interactions in life going forward. Attachment Theory has a leading position in understanding the mental health implications on children and their development as demonstrated in the case studies relating to Aaron, Mitchell and Matilde. In the case study of Aaron, we can understand how his early separation from his mother can be the reason he begins to stutter. As he moves into the adolescent phase and struggles with peer relationships he develops depression. The insecure attachment developed by Aaron in childhood due to the separation from his mother causes him to feel anger and rejection. He turns these feelings inwards resulting in the development of depression and suicidal thoughts. In the case study of Matilde, it is evident that the maltreatment that she is exposed to in her early years, such as sexual abuse, violence and abandonment, inhibits her ability to develop healthy relationships later in life and she turns to self-harming behaviours which puts her at risk of developing a personality order such as BPD. In the case of Mitchell, we see how maternal loss is one of the most traumatic experiences for a child. This highlights the importance of the mother and child attachment but also demonstrates the psychological difficulties that Mitchell faces due to this loss. He is diagnosed with PTSD following the loss of his mother and suffers additional difficulties such as unstable moods, anger outbursts, separation anxiety, and night terrors. Although psychopathology is not straight forward, it is important to acknowledge the significance that early experiences and mother/child attachment have in providing the framework for the way the child interacts with the environment thereafter. AT is not leaning towards the notion that there is an inherent glue that unites a mother and child, it is asserting that this relationship is the foundation from which the complex inner workings of the most important life relationships can be understood.


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