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Running Head: CBT and Attachment
Bosmans, G. (in press). Cognitive Behaviour Therapy for Children and Adolescents: Can Attachment Theory Contribute to its Efficacy? Clinical Child and Family Psychology Review.
Cognitive Behaviour Therapy for Children and Adolescents: Can Attachment Theory Contribute to its Efficacy?
Guy Bosmans, Ph.D., Parenting and Special Education Research Group, KU Leuven, Belgium
Correspondence to: Guy Bosmans,
[email protected], L. Vanderkelenstraat 32, 3000 Leuven, Belgium. tel. +32 16 32 61 87
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Abstract Meta-analyses consistently demonstrate that Cognitive Behaviour Therapy (CBT) provides effective evidence-based treatment for children and adolescents with emotional and behaviour problems. Also consistent across meta-analyses is the observation that CBT treatment effects are often medium in size. This observation has instigated a search for factors that could help explain the limited treatment effects and that could be focused upon to enhance CBT treatment outcomes. The current qualitative review focuses on the parent-child attachment relationship as one factor that could be relevant to enhance CBT treatment effects. This review first acknowledges reasons why CBT has historically not been attracted to attachment theory and its postulates. Second, recent evidence is examined to evaluate whether attachment can be approached from a cognitive schema perspective. Subsequently, research is described showing how restoring attachment relationships could result in large treatment effects. Finally, this evidence is integrated in a model of attachment assessment and intervention that might be compatible with CBT. In sum, this review suggests that restoring trust in insecure parent-child attachment relationships can be integrated within CBT and could contribute to its treatment outcomes. Keywords: children, adolescents, attachment, intervention, CBT
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Cognitive Behaviour Therapy for Children and Adolescents: A Literature Review to investigate whether Attachment Theory can contribute to Effective Treatment. Cognitive Behaviour Therapy (CBT) is one of the most clearly conceptualized and best-studied therapeutic approaches for treating children and adolescents (e.g., Seligman & Ollendick, 2011). Years of research confirm the positive effects of CBT and demonstrate significant reductions in a variety of child and adolescent emotional and behavioural problems (Hoffmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Part of the strength of CBT is its dynamic nature and flexibility to addressing these problems. Consequently, during the past decades, CBT with adults has broadened its treatment emphasis from focusing solely on changing behaviour, to focusing on challenging maladaptive cognitions, and, more recently, to accepting existential emotional distress (e.g., De Houwer, Barnes-Holmes, & BarnesHolmes, in press). CBT for children and adolescents has roughly followed these developments and benefited from them. This is illustrated by the increasing number of metaanalyses that confirm that CBT provides an effective treatment for a plethora of child and adolescent internalizing and externalizing behaviour problems (e.g., Reynolds, Wilson, Austin, & Hooper, 2012). However, meta-analyses also suggest that effect sizes often remain small to medium in size (e.g., Cuijpers, van Straten, Smits, & Smit, 2006; Kazdin, 1995; Klein, Jacobs, & Reinecke, 2007; Reynolds et al., 2012; Silverman, Pina, & Viswesvaran, 2008; Weisz, McCarty, & Valeri, 2006; Weisz et al., 2013) and that relapse rates following treatment are quite high (e.g., 30%-50% for mood disorders, Lewinson, Clark, Hops, & Andrews, 1990; Brent, Kolko, Birmaher, Baugher, & Bridge, 2005). This suggests that CBT for children and adolescents might benefit from a new conceptualization and expansion of treatment goals. The current literature review aims at providing arguments that one such expansion could be restoring attachment relationships. This paper will discuss the main components of traditional CBT for children and adolescents, argue why focusing on attachment relationships could add to traditional CBT, identify conceptual problems with attachment theory, review bridging
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research that approaches attachment from a cognitive schema perspective, and show initial support for the claim that restoring attachment relationships might yield large effects on emotional and behavioural problems. Traditional CBT for Children and Adolescents Child and adolescent CBT interventions can be broadly subdivided in interventions focused on children (further referred to as child-focused therapy or CFT) and interventions focused on parents (further referred to as parent-focused therapy or PFT). Typically, CFT aims at enhancing youngsters’ skills to deal with the challenges they encounter in their lives. For example, children learn to recognize and solve problems (e.g., Ugueto, Santucci, Krumholz, & Weisz, 2014), to challenge cognitions (e.g., Graham, 1999), to relax (e.g., HigaMcMillan, Frances, Rith-Najarian, & Chorpita, 2015), or to expose themselves to anxiety provoking stimuli or situations (e.g., Ollendick et al., 2009; Silverman et al., 1999). PFT focuses on improving parents’ pedagogical skills like rules setting, consequent disciplining, or positive reinforcement (e.g., Patterson & Forgatch, 1987). Additionally, PFT aims to help parents to provide the pedagogical context that fits best with their child’s specific needs (e.g., children with different temperamental characteristics require different parenting approaches; Van Leeuwen, Mervielde, Braet, & Bosmans, 2004). For CFT, a recent review of meta-analyses (Hoffmann et al., 2012) found medium effect-sizes for the CBT treatment of child and adolescent depression, suicidal behaviours, disruptive/aggressive/antisocial behaviours, smoking and substance abuse, sexual abuse survivors, obesity, and fecal incontinence. Stronger effect sizes were found for CBT focusing on chronic headache pain and large effect sizes for phobic and anxiety disorders. Nevertheless, even regarding anxiety disorders, a 2015 Cochrane Review showed that the remission rate, on average, is not larger than 58.9% and that longitudinal effects were understudied and revealed mixed results (James, James, Cowdrey, Soler, & Choke, 2015). For PFT, small to medium effect sizes were found across meta-analyses (e.g., Lundahl, Risser, & Lovejoy, 2006; Maughan, Christiansen, Jenson, Olympia, & Clark, 2005) and in the 2012
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Cochrane Review on PFT for young children (Furlong et al., 2012). Also, research on the effect of PFT on children’s externalizing problems suggests that PFT effects decline when the targeted children are older (e.g., Kazdin, 1995; Ollendick et al., 2015). These findings motivated clinicians to start combining CFT and PFT in the hope that this would enhance treatment effects. However, an increasing number of studies and metaanalyses suggest that adding PFT to CFT does not significantly improve treatment effects, again, independent of the targeted problem (e.g., Dowell & Ogles, 2010; Eimecke, Pauschardt, & Mattejat, 2010; Ollendick et al., 2015; Silverman et al., 2008; Thulin, Svirsky, Serlachius, Andersson, & Öst, 2014). These findings were surprising because the clinical impression exists that involving parents in CFT ought to be beneficial (e.g., Silverman et al., 2008). This raises the question about how CFT and PFT are combined and whether combining CFT and PFT disregards important components of parent-child relationships that need repair before treatment can be successful. In what follows, it is suggested that one such relational component is parent-child attachment. Evidence will be provided to show that parent-child attachment reflects the extent to which children have trust or confidence that they can rely on primary caregivers (e.g., parents, other family members, foster parents, adoption parents, teachers, or caregivers in residential centres) as a source for support during times of distress (Waters & Waters, 2006). If children are unable to develop trust, they feel disappointed in and rejected by their primary caregivers. Such breaches in trust, it is suggested, might interfere with the effects of both CFT and PFT. This would imply that, for children who lack trust in primary caregivers’ support, restoring attachment relationships by helping children to develop trust or helping them to overcome breaches in trust might be a crucial component of successful treatment. Attachment Theory According to attachment theory, children are born with a biologically determined behavioural system aimed at eliciting caregiver care and support during distress related to hunger, cold, pain, separation, anxiety, sadness, and fatigue (Bowlby, 1969). Although the
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caregiver in the majority of the cases (and in this review) refers to parents, any caregiver with whom the child has a long-term care-based relationship can become an attachment figure. According to Bowlby (1969), children’s experiences with caregiver responses to distress are internalized in internal working models. If children repeatedly experience responsive and sensitive care, they develop secure attachment working models. If parental care is absent, inconsistent or insensitive, children develop insecure attachment working models. These internal working models are important because they determine whether or not children can use the caregiver as a secure base from which they can freely explore their environment and whether or not children can use the caregiver as a safe haven to turn to when they need support during distress (Bowlby, 1988). Both the ability to explore the environment and the ability to use the caregiver as a resource are important for development (see also Figure 1). Exploration is crucial for children’s acquisition of knowledge and skills (e.g., emotion regulation) that are needed for an autonomous and healthy adolescent and adult life (e.g., Brumariu, 2015; Kashdan et al., 2009). Support seeking is also thought to be crucial to protect children against the maladaptive effect of distress encountered over time (e.g., Dujardin et al., 2016). ______________ Figure 1 ______________ Ainsworth further demonstrated that insecurely attached children respond differently to distress compared to securely attached children after separation from the primary caregiver (Ainsworth, Blehar, Waters, & Wall, 1978). Securely attached children seek proximity when distressed, are easily comforted by the caregiver upon reunion, and start quickly exploring their surroundings once again. Insecurely attached children typically show two different behavioural patterns. On the one hand, insecure-resistant or anxiously attached children seek proximity upon reunion but display signs of continued distress and even anger or resistance against the caregiver. Consequently, these children cling to their caregiver, which limits their
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further exploration. Insecure-avoidant or avoidantly attached children, on the other hand, seem to ignore their caregiver or refuse care after reunion. Instead, they appear to explore more. However, exploration never seems as free and natural as what is observed in securely attached children (Ainsworth et al., 1978). During the last decades, many studies demonstrated that insecure attachment is both cross-sectionally and longitudinally linked to increases in emotional and behaviour problems (Deklyen & Greenberg, 2008). Several meta-analyses (see also Madigan et al., in press) confirm this effect for the development of anxiety (e.g., Grohl, Roisman, van IJzendoorn, Bakermans-Kranenburg, & Fearon, 2012), depression (Brumariu & Kerns, 2010), and externalizing behaviour problems (Fearon, Bakermans-Kranenburg, van IJzendoorn, Lapsley, & Roisman, 2010). Many separate studies support this effect for a list of other problems such as dissociation (Liotti, 2006), eating pathology (Goossens, Braet, Van Durme, Decaluwé, & Bosmans, 2012), non-suicidal self-injury (Bureau et al., 2010), or even the symptomatology and course of schizophrenia (Ponizovsky, Nechamkin, & Rosca, 2007). As a consequence, insecure attachment is considered an important transdiagnostic risk factor in the development of psychopathology and could therefore be an important factor to take into account during the treatment of any child and adolescent emotional or behavioural disorder. Across diagnoses, the mechanisms that explain maladaptive development are supposed to be the same (see Figure 1). Due to decreased exploration, insecurely attached children develop less skills to adequately cope with distress and due to decreased support seeking, distress endures and has a stronger maladaptive effect on development (Cassidy, 1994). However, other factors such as temperamental characteristics of the child, specific learning experiences, and other contextual factors are important to understand which specific symptoms insecurely attached children eventually develop, (multifinality; Cicchetti & Rogosh, 1996). Note that this does not mean that insecure attachment is always involved in the development of psychopathology symptoms (equifinality).
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Although these findings seem to suggest that CBT might benefit from integrating attachment-focused interventions with traditional CBT interventions, CBT has long expressed scepticism and valid concerns about the value of attachment theory. For some CBT therapists, attachment theory is questionable due to its close link to psychodynamic theory (e.g., McBride & Atkinson, 2009). In contrast, attachment researchers (e.g., Crittinden, 2002) proposed that attachment theory allows to be integrated within CBT. Although this work was fundamental as a first bridge between the two traditions, it was mostly based on conceptual argumentation and little on empirical evidence demonstrating that basic concepts of attachment theory can indeed be approached from a cognitive perspective. Nevertheless, attachment theory did start influencing the theoretical underpinnings of more recent CBT treatment models like Schema-focused therapy (Kellogg & Young, 2006; Young, Klosko, & Weishaar, 2003) and Compassion-focused therapy (Gilbert, 2010). Although this suggests an increasing openness for attachment theory in CBT, these models do not integrate an attachment focus in their treatment strategies. In other words, thus far, restoring attachment relationships has not been explicitly integrated in CBT as a specific treatment goal. Apart from ideological arguments, several aspects of attachment theory and research make the theory difficult to combine with CBT practice. For example, CBT requires concepts to be clearly defined, pathogenic mechanisms clearly demonstrated, concepts to be malleable, and therapy to be evidence based. Regarding all these requirements, many scholars have expressed serious and justified concerns (e.g., Rutter, 1995; 2014) and even scepticism about the overall value of attachment theory (e.g., Bolen, 2000). First and most importantly, attachment theory’s definitions of core constructs have too long been overly vague and metaphorical (e.g., Waters, Corcoran, & Anafarta, 2005). This is most problematic for the internal working model construct (e.g., Waters & Waters, 2006; Thompson, 2008). According to Bowlby (1969), the internal working model is a mental representation reflecting internalized experiences with (lack of) attachment figure care in response to distress. This construct is crucial for attachment theory because it should explain
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why early caregiver-child interactions influence later child development (see above). However, the meaning of terms like “internalization”, “working model”, or “representation” remains cause for ongoing debate (e.g., Rutter, 2014; Thompson, 2008). For CBT this would have made it hard to develop treatments focused on insecure attachment relationships: if it is unclear what specifically needs to be changed, it is unclear how change could be accomplished. Second, in spite of the clear links between attachment and emotional and behaviour problems, insecure attachment is not a synonym of psychopathology (e.g., Hinde, 1982), with the majority of insecurely attached individuals functioning in an adaptive way (e.g., Zilverstein, 2006). Nevertheless, it has long remained unclear which moderators determine the link between insecure attachment and emotional and behavioural problems, and which mechanisms explain these links (Deklyen & Greenberg, 2008; Brumariu & Kerns, 2010). Again, this made attachment less interesting for CBT: if it is unclear why attachment is important for the development of psychopathology, it is unclear why working on attachment relationships could be beneficial for children and adolescents. Third, attachment theory has long emphasized the stability of children’s secure versus insecure attachment (Bowlby, 1969) and, in its early years, longitudinal studies seemed to confirm that assumption (e.g., Waters, Hamilton, & Weinfield, 2000). This eventually led to the perception that attachment (in)security is not malleable. Again, this made attachment less interesting as focus for (CBT) treatment: if you cannot change a problem, it is less useful to focus your treatment on changing that problem. Finally, although throughout the years many therapies claimed to provide attachment therapy, many of these therapies were never really tested. On the contrary, holding therapy, during which extremely angry and/or aggressive children were held physically close to the caregiver until the anger declined, was a treatment that was labelled as attachment-focused, but eventually turned out to be traumatizing and even lethal (Lilienfeld, 2007). In contrast, evidence shows that interventions can effectively promote parenting behaviors like sensitive
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parenting that are considered critical for a secure attachment development (Verhage et al., 2016). Examples are the Video-Feedback Intervention to Promote Positive Parenting and Sensitive Discipline (VIPP-SD; Alink et al., 2006), the Circle of Security (Hoffman et al., 2006), or the Parent-Child Interaction Therapy (PCIT; Chaffin et al., 2004). These interventions are designed like other CBT-like PFTs and have small to medium effect sizes on parenting behaviors and symptoms of psychopathology of the child. This is comparable to what is found for other evidence-based PFTs (e.g., Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003). However, most of these interventions focus on early childhood and, as far as they have been tested, have only limited impact on (older) children’s attachment development (Bakermans-Kranenburg et al., 2003). Also a recent overview of child and adolescent treatments for child anxiety disorders found no evidence in support of the effect of attachment-focused interventions (Higa-McMillan et al., 2015). Consequently, it has long remained unclear, especially in older children, whether and how insecure attachment to caregivers can be restored to help reduce symptoms of psychopathology of the child. New Developments in Attachment Theory that are relevant for CBT In spite of these concerns, it is important to note that more recent lines of research have begun to empirically close the conceptual gap between attachment theory and CBT. Most importantly, secure internal working models appear to consist of cognitive schemas and scripts (the Secure Base Script, SBS) and related expectations (trust in the availability of the attachment figure’s support). Second, there is an increasing insight in the mechanisms that explain the link between insecure attachment and emotional and behaviour problems. Third, an increasing number of studies show that attachment is not highly stable over time throughout childhood and adolescence. Finally, novel treatment strategies have been developed aimed to restore ruptures in attachment relationships. These developments will now be more thoroughly discussed.
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The Secure Base Script Concept Recent, but accumulating research shows that the internal working model refers to a memory of repeated experiences of sensitive and responsive (secure base) support from caregivers that are stored in a cognitive script-like fashion (e.g., Steele et al., 2014). This Secure Base Script (SBS) consists of main characters, a causal chain of events and a resolution or ending. More specifically, the script starts with the experience of distress. This activates a chain of events consisting of signalling distress to caregivers, caregivers’ detection of these signals, and caregivers’ prompt and supportive response to these signals. This response, in turn, helps in resolving the distress and puts the individual back on track (Waters & Waters, 2006). Individuals who experience consistent secure base support throughout development have more knowledge about the script and can more easily access the script during distress to motivate them to seek proximity and support (e.g., Waters, Brockmeyer, & Crowell, 2013; Waters & Waters, 2006). This can be measured using a prompt word assessment procedure. Table 1 illustrates one item of the middle childhood version of the SBS assessment (for more information about the test, see Waters & Waters, 2006). This test allows to identify whether an individual has a SBS or not. Participants are asked to tell a story using a list of prompt words that loosely suggest a secure base script-like event (Table 1). Waters and Waters (2006) demonstrated that individuals who have a SBS are more inclined to tell a SBS-like story using these words compared to individuals who do not have a SBS. Evidence that sensitive and responsive care-related experiences are stored in a SBS-like fashion has been found across the life-span: in toddlers (Waters, Rodrigues, & Ridgeway, 1998), middle childhood (Waters, Bosmans, Vandevivere, Dujardin, & Waters, 2015), adolescence (Dykas, Woodhouse, Cassidy, & Waters, 2006), and adulthood (Waters et al., 2013). Eventually, research suggests that this script becomes the blue print of other (care-related) relationships (Waters, Fraley, et al., 2015).
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The SBS is linked with the expectation that one can trust in the availability of the support of attachment figures. As has been found for other expectations, individual differences in self-reported trust are linked with biases in the cognitive processing of attachment-related information across the lifespan (e.g., Dykas & Cassidy, 2011; Zimmermann & Iwanski, 2015). For example, in middle childhood, children who trust less in the availability of their mother interpret maternal behaviour in a more negative way, even if her behaviour can just as well be interpreted as supportive (De Winter, Waters, Vandevivere, Braet, & Bosmans, in press). Also, these children remember more negative interactions with mother - at the expense of remembering positive interactions with her (Dujardin, Bosmans, Braet, & Goossens, 2014). Finally, children’s attentional processing of their mother is biased when they trust less in her availability. These biases were measured with computerized tasks. The direction of the latter bias depends on whether cognitive processing occurs more automatically or more strategically. At the initial or more automatic stages of information processing, children who trust less in maternal availability have a stronger attentional focus on mother. On the one hand, they more quickly orient their attention towards mother (Bosmans, De Raedt, & Braet, 2007). This means that their attention is more easily drawn towards mother. On the other hand, they have a more narrow attentional field around mother (Bosmans, Braet, Koster, & De Raedt, 2009). This means that if their mother appears in the centre of their attentional field, these children have more difficulties to encode other stimuli presented farther from the centre of their attentional field. In both cases, these findings are in line with the observation in infant attachment research that insecurely attached children are impaired in their ability to freely explore their environment, away from mother. Confirming the relevance of these automatic attentional biases, a stronger attentional focus on mother has been shown to be related to reduced support seeking during distress (Bosmans, Heylen, Braet, & De Raedt, 2015) and to reduced exploration of mildly arousing stimuli (Dujardin, Braet, De Raedt, & Bosmans, 2015). Furthermore, at later, more strategic stages of information processing, this
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direction of effect shifts with less trust being linked to attentional avoidance of mother (Vandevivere, Braet, Bosmans, Mueller, & De Raedt, 2014). The automatic attentional focus on mother and strategic attentional avoidance of mother in children with less trust suggests that for insecurely attached children the mother is an important stimulus that nevertheless has a negative valence. This may help to explain the ambivalence towards caregivers observed in many insecurely attached children. The SBS definition of internal working models and the evidence that different trustrelated expectations bias the cognitive processing of attachment-related information has also stimulated new research on the processes involved in short-term attachment development. Although this line of research is still new, clinically relevant findings have already emerged. This research has shown that attachment consists of trait- and state-like components (Gillath, Hart, Noftle, & Stockdale, 2009) and that state-like attachment can be affected by the context in which attachment states are activated (Rowe & Carnelley, 2003). For example, an experimental RCT study measuring state attachment one week before the experiment and immediately after the manipulation, showed that asking individuals to recall positive attachment experiences, causally increased secure attachment states. The same study showed that asking individuals to recall negative attachment experiences causally reduced secure attachment states (Bosmans, Bowles, Dewitte, De Winter, & Braet, 2014). In another state attachment study, diary data showed that children with high trait trust report stable and high state trust scores over time independent of whether or not they experienced conflicts with mother. Instead, children with low trait trust fluctuate more in their state trust over time: on days when they reported no conflicts with mother, they reported higher state trust, while on days with more conflicts, their state trust decreased (Bosmans, Van de Walle, Goossens, & Ceulemans, 2014). This suggests that children with a high trait trust score process trust-incongruent experiences (like conflicts with mother) in such a way that it does not change their overall appraisal of mother as a source for support. This phenomenon is typically described as assimilation, a process known to be characteristic of
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cognitive schemas. Intriguingly, the fact that children with low trust scores have more fluctuating trust states suggests that they probably do not have a script about lack of care because this should have resulted in consistent low state trust scores over situations. Instead, it suggests that they probably lack any script about care. These state attachment studies suggest that clinicians should be vigilant for premature conclusions about a child’s secure attachment based on single observation moments. In sum, within attachment research, there is increasing evidence that attachment can be approached from a cognitive schema perspective, with the information processing biases, the state and trait components, and related (lack of) assimilation processes that are typically the focus of CBT. Due to the novelty of this gradual conceptual shift, most studies are crosssectional by nature and use general population samples. However, the SBS conceptualization is supported by an increasing number of longitudinal studies (e.g., Vaughn et al., 2015), and the effects could be replicated in a limited number of clinical samples (e.g., Bosmans, Koster, Vandevivere, Braet, & De Raedt, 2013). This means that more longitudinal and clinical research is needed to further corroborate the clinical relevance of these findings. Nevertheless, the findings are important because they help to significantly close the conceptual gap between attachment theory and CBT. Moderators and Mechanisms explaining Links Between Attachment and Emotional and Behavioural Problems In the last decade, several moderators and mediators have been identified that help explain which less securely attached children and adolescents are more at risk to develop emotional and behavioural problems and why. At the level of moderators, studies so far showed that the link between attachment and psychopathology depend on the child’s attachment-related information processing biases, the child’s psychophysiological responses to emotional information, and the amount of distress during the child’s development. First, in line with predictions from the dual process theory (e.g., Gawronski & Creighton, 2013), automatic and strategic attachment-related processes interact in the explanation of symptoms
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of psychopathology. Three studies found that lack of self-reported trust (strategic process) was only linked to symptoms of psychopathology when children had a more narrow attentional field around mother (automatic process). This was found for both internalizing and externalizing behavior problems (Bosmans, Koster, et al., 2013) and for non-suicidal selfinjury (Claes, De Raedt, Van de Walle, & Bosmans, 2016). Consequently, this seems to suggest that only when children are strongly focused on mother, a low quality attachment relationship puts children at elevated risk to develop emotional and behavioural problems. Second, one study found that whether or not anxious attachment was linked to depressive symptoms, depended on skin conductance responsivity to emotional stimuli. Only when children’s skin conductance levels fluctuated more in response to neutral, positive, and negative stimuli, more anxiously attached children were more at risk to display depressive symptoms (Bosmans, Poiana et al., in press). Although more research in this area is needed to replicate these findings, this seems to suggest that other (temperamental) child factors determine whether insecurely attached children are at risk to develop emotional and behavioural problems. Third, at the level of the developmental context, longitudinal research suggests that insecure attachment and related lack of support seeking behaviour is only linked to the development of depressive symptoms when children are exposed to higher levels of distress. Less securely attached children do not develop depressive symptoms when they experience less distress during their development (Dujardin et al., 2016). At the level of mechanisms, an increasing number of mediation studies suggest that emotion regulation strategies, self-regulation capacity, and cognitive vulnerabilities explain the link between attachment and psychopathology. First, with regard to emotion regulation strategies, there is abundant and robust evidence that insecurely attached children are at risk to develop emotional and behavioural problems because they fail to adequately regulate negative emotions (Brumariu, 2015). While more securely attached children are more likely to seek attachment figure support as a protection against long-term maladaptive effects of distressing life events (Dujardin et al., 2016), less securely attached children are less inclined
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to seek proximity and support (Dujardin et al., 2016, Claes et al., 2016). Instead, they start developing maladaptive strategies to regulate the negative emotions they experience during distress (Cassidy, 1994). Which strategies they develop depends on whether they are more resistant/anxiously or more avoidantly attached (Brenning et al., 2012; Brumariu, 2015; Cassidy, 1994). More resistant or anxiously attached children are more likely to be overwhelmed by negative emotions. Moreover, they tend to heighten their negative emotional states (for example by ruminating about negative emotions or by expressing anger about the attachment figure’s failure to be responsive and sensitive) to elicit care (Cassidy, 1994). At the same time, any care they receive activates fear to be again disappointed by the caregiver’s rejection, abandonment, or neglect (Brenning et al., 2012; Cassidy, 1994). This has been described as an hyperactivating emotion regulation strategy (Mikulincer & Shaver, 2007). More avoidantly attached children are likely to refuse care from attachment figures. Instead, they try to ignore or suppress (negative) emotions (Brenning et al., 2012; Brumariu, 2015; Cassidy, 1994). They more likely avoid situations that elicit negative emotions, but also positive emotions. Hence, this has been called a deactivating emotion regulation strategy (Mikulincer & Shaver, 2007). Moreover, research suggests that less securely attached children show more emotional and behavioural problems because they have less capacity to effortfully control automatic emotional responses to negative situations and stimuli (Eisenberg et al., 2001; Heylen et al., in press). This probably enhances the negative effect of maladaptive (automatic) emotion regulation strategies on children’s development of emotional and behavioural problems. In this manner, insecure attachment refers to the relational context in which children become at risk to develop different cognitive vulnerabilities for emotional and behavioural problems that often are the focus of CBT treatments. Three examples are the specificity of Autobiographical Memories (AMspecificity), rumination, and early maladaptive schemas. Regarding AMspecificity, research suggests that children who trust less in maternal support
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are less inclined to communicate about their experiences with their parents. Less communication decreases children’s ability to recall specific autobiographic attachment memories. This is linked to an increased risk for depressive symptoms (Bosmans, Dujardin, et al., 2013). In the same vein, research shows that less securely attached children are more likely to develop emotional problems because of elevated rumination about negative affect (e.g., Ruijten, Roelofs, & Rood, 2011) and about mother (Van de Walle et al., in press). Finally, several studies in clinical and general population samples show that less secure attachment is linked with many different symptoms of emotional and behavioural problems through the development of those early maladaptive schemas that are the target of Schemafocused Therapy (e.g., Bosmans, Braet, & Van Vlierberghe, 2010; Roelofs, Onckels, & Muris, 2013; Roelofs, Lee, Ruijten, & Lobbestael, 2011). In sum, accumulating research suggests that not all insecurely attached children will develop emotional and behavioural problems. Only in the presence of child- and contextrelated risk factors such as children’s biased cognitive processing of attachment-related information, temperamental vulnerabilities, and high levels of distress, these children are at risk. This means that a therapist needs to evaluate which are the risk factors that explain why a referred insecurely attached child developed problems. In case insecure attachment does play a role in a referred case, the therapist needs to evaluate how the child developed these problems. Identifying maladaptive emotion regulation strategies and self-regulation issues can help design specific intervention strategies, some of which are well-developed in CBT but are not frequently used to explicitly target the relational strategies a child uses to cope with distress. The (In)stability of Attachment Relationships In spite of the overall accepted idea that attachment is a fairly stable construct (e.g., Bowlby, 1969), it was only since the beginning of the 21st century that attachment researchers had access to samples that were followed up long enough to conduct the longitudinal analyses needed to test this idea (e.g., Hamilton, 2000; Lewis, Feiring, & Rosenthal, 2000; Waters et
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al., 2000; Weinfield, Sroufe, & Egeland, 2000). In spite of some inconsistencies across studies, the general impression was that these studies confirmed Bowlby’s stability assumption. However, ever since, more longitudinal data emerged and two meta-analyses showed correlations between infants and adolescents that averaged around .39 (Fraley, 2002; Pinquart, Feußner, & Ahnert, 2013). Because all these separate studies suffered from small sample sizes (across all studies, total n = 785), a recent study attempted to replicate the initial longitudinal effects in a sample of 857 participants and found a correlation of .12 (Groh et al., 2014). These meta-analyses, and the latter study suggest that attachment is far from a stable construct. Instead, there is an increasing awareness that changes in the quality of parent-child interactions can alter children’s attachment development throughout childhood and adolescence. Together with children’s cognitive and social maturation, the characteristics of a secure parent-child attachment relationship alter in response to the increasing complexity of children’s developmental tasks (Mayseless, 2005). In every phase in life, this requires specific skills for parents and children to acquire or display in order to assure the development of secure attachment (see Figure 2 for an overview).
________ Figure 2 ________
In the first years in life and early childhood, parents are crucial to promote survival (Bowlby, 1969). The main developmental goal of a young child is to discover the world and to master basic motor and cognitive skills. At this age, parents are a secure base if they responsively provide proximity and support for basic biological needs such as food to overcome hunger, or comfort for pain and fears (Bowlby, 1969). Additionally, it is important that parents can express that they experience joy when they see their children play and
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explore (Hoffman et al., 2006). In summary, early in life, children’s use of the parent as a safe haven and children’s attachment development depend mainly on parents’ ability to respond to children’s needs and less on children’s characteristics (Vaughn, Bost, & van IJzendoorn, 2008). This explains the effectiveness of the aforementioned early intervention programs that focus on training parents to be more sensitive and responsive. Middle childhood is a biological switch period initiated by the increased activation of the adrenal gland (adrenarche). This leads to elevated secretion of hormones that enhance sexual and social awareness and that improve social script learning (Del Giudice, 2015). This developmental shift coincides with increased time spent away from the family (e.g., at school or for hobbies). At this age, parents retain their secure base function for basic biological needs, but there is also an increased need for parental support regarding academic and social distress (e.g., learning difficulties or social conflicts at the playground; Vandevivere, Bosmans, & Braet, 2015). Moreover, the safe haven mechanism changes. For most of these challenges, children no longer require parents to take over and to solve problems for them. Instead, they need them to be a coach who helps them understand each new problem, who proposes possible solutions, and who allows children to autonomously apply and ameliorate suggested solutions (Koehn & Kerns, 2015). Consequently, especially for mildly distressing challenges, it becomes most adaptive if children autonomously solve problems (Bosmans, Dujardin, Field, Salemink, & Vasey, 2015; Dujardin et al., 2015). In contrast, for more severe distress, it becomes most adaptive if children learn to autonomously seek parental support (Dujardin et al., 2016). With other words, middle childhood is a period of substantial attachment development during which children need to acquire the cognitive script and the related skills to enable them to actively seek support in this changed relationship (Mayseless, 2005). Although children become a more active partner in this process, the quality of the interactions with parents can improve or deteriorate their attachment development. Children need to have acquired these cognitive skills before the onset of adolescence, to ensure that they have access to parental support during a time when they are mostly away
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from home to experiment with peers and first romantic relationships. Due to hormonal changes, novel challenges, and an elevated search for autonomy, adolescence is a turbulent developmental period (Steinberg, 2008). The best adjusted adolescents are able to use parents as a resource once they feel that they lack sufficient problem solving capacity to overcome distress (e.g., Offer et al., 1991). To remain a secure base, this requires parents to find a healthy balance between allowing their children increasing intellectual and emotional autonomy and remaining available and sensitive to their adolescents’ support needs (e.g., Baumrind, 1991). This can be especially difficult in a period when adolescents often challenge their parents. However, throughout conflicts and discussions, a secure base parent typically manages to remain attuned to the adolescent’s emotional state (Allen et al., 2003). Moreover, during conflicts and discussions, secure base parents and securely attached adolescents remain expressing their relatedness (Allen et al., 2003). This implies that also during adolescence positive or negative changes in quality of parent-child interactions can have beneficial or negative effects on attachment development. Finally, attachment development continues during young adulthood and beyond. A complication here is that young adults often move out of house and are away from parents. This requires even more active effort from the child to seek parents’ secure base support. Nevertheless, clinical experience suggests that even at this age, secure attachment relationships are critical for a healthy development (Santens,et al., 2016). In sum, a parent can only be a safe haven if the adolescent decides to communicate about distress (Allen et al., 2003). This is one important reason why restoring adolescent/young adult insecure attachment relationships requires more than training parents to be more responsive, but rather requires involving both parents and adolescents in treatment. Next to instability over time, attachment-related expectations also appear to be variable over attachment figures. For example, children can be more securely attached to mother and less to father (Doyle, Lawford, & Markiewicz, 2009; Walper & Wendt, 2015). This observation leads to important clinical questions regarding whether individuals develop
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a general SBS or whether they develop SBSs for each separate caregiver/attachment figure (e.g., Waters, Fraley, et al., 2015). Although the discussion regarding this question is ongoing, research suggests that early in life scripts are relationship specific (Van IJzendoorn & Wolff, 1995), but throughout childhood and towards the end of adolescence the SBS gradually generalizes over attachment relationships (Waters, Fraley et al., 2015). This, again, suggests that important attachment development occurs beyond early childhood and that novel attachment-related experiences can have an important impact on SBS development. In summary, research has provided evidence to suggest that, contrary to popular belief, attachment relationships do change and childhood and adolescence could be a critical period in life to work in therapy on attachment-related issues. In sum, these studies warn against overly pessimistic expectations regarding the treatability of insecure parent-child attachment relationships Evidence Based Attachment-focused intervention strategies As demonstrated above, insecure attachment reflects painful experiences of parental rejection and/or insufficient parental availability/care that biases the way new attachment information is processed. This suggests that, at least for older children and adolescents, changing attachment-related expectations or trust in the availability of the caregiver requires strategies that help look beyond these biases. Evidence for this suggestion was found with two different recently developed attachment-focused intervention strategies: AttachmentBased Family Therapy (ABFT; e.g., Diamond, Siqueland, & Diamond, 2003) and attachmentfocused Cognitive Bias Modification (CBM_A; De Winter, Bosmans, & Salemink, in press). ABFT is a protocolized treatment that is developed to treat depressed and suicidal adolescents (13-18 years old; without psychosis or autism) by restoring the parent-child attachment relationship (Diamond, Diamond, & Levy, 2014). ABFT aims at creating corrective attachment experiences that change adolescents’ perception of the parent as a source for support. To achieve this goal, the treatment focus is redirected from solving the depression (and suicide) to repairing the parent-child relationship. Then, the therapist works
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individually with the adolescent and the parent to prepare both for a conversation about the adolescent’s experiences that damaged his/her trust in the parent as a source for support. Adolescents are prepared to share the pain and disappointment they experienced during previous attachment-relevant interactions with parents. In separate sessions, parents are prepared to provide sensitive and responsive care for their adolescent’s negative attachment experiences. ABFT’s mechanism of change relies on the assumption that sharing these experiences activates the adolescent’s fear system, comparable to exposure therapy. At the start of the conversation, the adolescent’s fear for novel rejection is elevated, but the experience that parents are able to listen to the adolescent and can give care and comfort for the experienced relational distress is a highly intensive emotional and new experience that repairs his/her trust in parental availability for care and support. As a result, depressed adolescents learn to use the parent as a resource to help regulate the distress that caused the depression and, eventually, depressive symptoms decline. Currently, 5 studies (two open trials, three RCTs) have been published by Diamond and his colleagues. Results suggest that this intensive emotional interpersonal experience and the restoration of the parent-child attachment relationship is highly effective in reducing depressive symptoms. This is reflected in large effect sizes within treatment, in large effect sizes compared to Waitlist (d = 1.21; Diamond et al., 2002; Weisz et al., 2006) and small effect sizes compared to Enhanced Usual Care for depressive symptoms (d = .37 posttreatment and d = .22 at follow up; Diamond et al., 2010), and in large effect sizes compared to Enhanced Usual Care for suicidal ideation (d = .95 post-treatment and d = .97 at follow up; Diamond et al., 2010). Additionally, a small ABFT RCT study found large effect sizes compared to Treatment as Usual for depressive symptoms after dissemination in a Norwegian hospital (ds range from .80 to 1.08 depending on instrument used; Israel & Diamond, 2012). Adding to the potential relevance of repairing family relationships to treat these youngsters, these treatment results seem (unlike CBT; e.g., Barbe et al., 2004; Lewis et al., 2010) not affected by sexual trauma history (Diamond et al., 2012). Finally, preliminary results suggest
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that adolescents’ attachment anxiety and avoidance decrease after ABFT (Shpigel, Diamond, & Diamond, 2012). On the one hand, this overview shows that ABFT as a treatment model is a promising treatment, that is, however, still in its infancy. The amount of ABFT research remains limited compared to the vast CBT treatment evaluation research, and ABFT effects have thus far only been investigated by one research group (while evidence based criteria require that results are replicated in at least two independent groups). Consequently, more research is needed to be confident of ABFT’s therapeutic value. On the other hand, this research seems to provide convincing support for the current review’s hypothesis that insecure attachment is malleable through protocolized treatment. In future research, it would be interesting to see whether CBT effects could increase for insecurely attached youth when treatment takes into account the breaches in trust and frustrated needs for care and support. Finally, a recent CBM_A study aimed to increase trust in maternal availability for support by training secure attachment-related interpretation biases in middle childhood (De Winter et al., in press). To achieve this, De Winter et al. (in press) developed a training that was based on the CBM paradigm developed by Mathews and Mackintosh (2000). During this training, children learned to interpret ambiguous mother-child care-related interactions in a secure way (mother provides support). Using a RCT design, children were attributed to the training or to a placebo condition. Before and after the training/placebo, children’s interpretation bias and trust in maternal support was measured. Results showed that after CBM_A children interpreted ambiguous maternal behaviour in a more secure way and that training children’s secure interpretations increased trust in maternal availability. Although this is only one study that needs replication, the results are a first small and encouraging indication that biases in the processing of attachment-related information might be malleable. Moreover, it is unclear whether such trainings can help reduce symptoms of psychopathology. If future research would find support for such effects, this line of research could eventually lead to new perspectives on improving insecure attachment relationships.
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Implications of contemporary Attachment Theory and Research for CBT Treatment In summary, contemporary attachment research has provided evidence that attachment security versus insecurity reflects at its core whether or not children have been able to develop a secure base script and whether or not children have the expectation that they can trust in their parents’ availability to provide support during distress. Trust is crucial in children’s adaptive development because it increases the likelihood that they actually seek support when needed (Bosmans, Braet, et al., 2015). If trust is lacking, children develop less secure attachment information processing biases and maladaptive emotion regulation strategies (Bosmans & Kerns, 2015). Which maladaptive emotion regulation strategies they use depends on whether they become more anxiously or more avoidantly attached. Fortunately, attachment development is affected by new interpersonal experiences throughout childhood and adolescence. Consequently, insecure attachment is not a stable trait. Moreover, although the support is limited, protocolized treatment that focuses on restoring that parentchild attachment relationship seems to significantly increase secure attachment and seem to be able to effectively treat related emotional and behaviour problems. Attachment and CBT treatment effects Based on this review, it seems reasonable to argue that one strategy to enhance CBT effects might be through broadening CBT’s focus to attachment relationships. Contemporary attachment theory and research suggests that, at least for part of the treated children and adolescents, lack of trust in caregiver support might interfere with traditional CBT strategies. The specific explanation is likely different for CFT and PFT. For CFT, it might be that for insecurely attached youth (1) the treatment in its current form insufficiently targets these children’s experiences of absent care that continue to cause feelings of loneliness through ongoing disappointment and/or frustration, and (2) because their attachment figures continue to function as a discriminative stimulus which can interfere with the transfer of acquired skills from the therapy room to the home environment. Consequently, it could be that for these
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children, restoring trust in parental support could be important to enhance CBT treatment effects or to protect them against the risk to relapse. For PFT, it seems reasonable to suggest that for insecurely attached children, PFT treatment effects would remain limited, because (1) disappointment, lack of trust and related attachment-related information processing biases might reduce the likelihood that these children observe changed parenting behaviours, and because (2) parents might be more likely to relapse in old parenting habits if children are not responsive to their efforts to adjust their parenting behaviour to their child’s needs. Based on these suppositions one can also argue that the limited additional effect of CFT+PFT combinations can also at least partly be explained from attachment theory: in spite of the fact that involving parents in the treatment of children and adolescent is important (which was supported by observations noted in Silverman et al., 2008), it could be that traditional CFT+PFT strategies fail to address the lack of trust that appears to be so important in the development of insecurely attached children and adolescents’ emotional and behavioural problems. Although this sounds like a good hypothesis, to date it remains speculative and calls for further research in this area. To date, little research exists that directly tests the hypothesis that insecure attachment decreases child and adolescent CBT effects. A small number of studies on other treatment models suggest that attachment might indeed moderate treatment effects. One study with depressed adult inpatients found that only securely attached individuals benefited from therapy (Reiner et al., 2016) and also a recent meta-analysis of research on attachment and treatment outcomes provided initial support for this moderation hypothesis (Levy, Ellison, Scott, & Bernecker, 2011). However, also the latter meta-analysis only focused on treatment of adult patients and collapsed different therapy orientations (including CBT). So no conclusions can be drawn for child and adolescent CBT. Nevertheless, it seems reasonable to predict that the same effects might be found for child and adolescent CBT. Interestingly, the latter meta-analysis suggested that the moderating effect of attachment on therapy outcomes was stronger in younger patients. This adds to the current review’s argument that focusing on
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restoring the parent-child attachment relationship might increase the effect of child and adolescent CBT for some patients. Moreover, it calls for measuring attachment in future child and adolescent CBT intervention research. Attachment and case conceptualization The currently reviewed attachment studies might be important to understand how (in)secure attachment and related behaviour might be captured in traditional (C)BT functional analysis models of classical and operant conditioning. At the level of classical conditioning (see Figure 3) securely and insecurely attached children have different learning histories. Securely attached children learn that their (sensitive) parent (Conditional Stimulus, CS) becomes associated with the experience that distress is responded to by care and comfort (Unconditional Stimulus, UCS), which is associated with relief of distress (Unconditional Reaction, UCR). If ‘mother’ and ‘relief of distress’ are repeatedly associated through time, children develop trust in the sensitive caregiver (Conditional Reaction, CR). Which (parental) responses to distress support the formation of this CS-CR association depend on the child’s developmental stage. In infancy, this can be prompt responses to basic biological needs such as hunger, cold, or overstimulation (Ainsworth et al., 1978). In middle childhood, this can be for example parental behaviour aimed at helping children understand the complex rules of social peer-relationships (Vandevivere, Braet, & Bosmans, 2015) to enable the child to solve social problems autonomously (Bosmans & Kerns, 2015). In adolescence, this can be for example parents’ ability to remain related and emotionally attuned to their adolescent in spite of having (autonomy-related) discussions and conflicts (Allen et al., 2003). Insecurely attached children have other learning experiences. They link their (insensitive) parent (CS) to the repeated experience that the parent is unresponsive during distress (UCS) which leads to maintained distress, frustration, and feelings of disappointment (UCR) and the expectation that it is better not to rely on the parent as a source of support (CR). Theory and research suggest that this learning history is comparable across diagnoses (Waters, Bosmans et al., 2015). The following examples of experiences that caused ruptures
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in children’s trust in their parents’ support are drawn from own clinical practice1. The examples aim to illustrate that (1) different emotion and behavioural problems can all have in common an insecure attachment learning history, that (2) different types of experiences can create ruptures in attachment relationships, ranging from repeated experiences of smaller disappointments in the relationship (e.g., case Lisa) to severely traumatizing events (e.g., case John), and (3) that these ruptures can occur at all ages.
_________________ Insert Figure 3 here _________________
A first example is Lisa, a 15 year old girl whose parents were absorbed by taking care for her profoundly intellectually disabled younger sibling. Lisa was referred to treatment after a second suicide attempt. Her ruptures related to several experiences during which she experienced distress (e.g., after a breakup, after academic failure) and during which she acutely felt the absence of her parents’ care. After the breakup, she signalled her grief to her mother, but her mother immediately minimized the breakup saying that it was puppy love and that there was no need to feel bad about it. This gave her the feeling that her mother was not interested in how she was feeling, which induced a sense of loneliness and isolation. At the end of her second year in middle school, she failed to pass and had to change study (implying changing school and friends). Although this made her very sad, her father only blamed her for not having put enough effort in her studies. This gave her the impression her father did not love her and only saw her failure. These and similar experiences made Lisa think that she was not important enough for her parents to take care for her as much as they took care for her sibling.
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The second example is John, a nine-year-old boy. He lived with his sister in a residential child welfare care unit. He was referred for treatment because he ended up in constant fights with his six-year-old sister. He lost trust in his mother’s support after accumulating conflicts. These conflicts typically started with mother calling him names and other verbal abuse in response to his rule-breaking behaviour. Next, mother would abruptly leave the house, leaving him alone with his younger sister for hours. The combination of the distress induced by mother’s anger with the sadness and fear experienced after being abandoned (and left alone with his upset little sister) resulted in John’s belief that he could not rely on her for support. At the level of operant conditioning (see Figure 4), different behavioural patterns can develop depending on whether children are securely or insecurely attached. When securely attached children experience distress (Discriminative Stimulus, Sd), they can seek care and support (Response, R), which is reinforced by the reduction or avoidance of the distress (-S-or ° S-) and the subsequent sense of security and love (+S+) (Reinforcing Stimuli, Sr, see also Sroufe & Waters, 1977). Throughout development, the behaviours that serve to elicit this sense of being supported and being cared for change hand in hand with children’s increasing cognitive maturation (Bosmans & Kerns, 2015). For example, young children mainly seek physical proximity to receive support (e.g., Ainsworth et al., 1978), while older children might just as well have a phone call with mother to experience the same sense of support (e.g., Seltzer, Ziegler, & Pollak, 2010). _________________ Insert Figure 4 here _________________
Instead, when children are insecurely attached, they will respond to distress (Sd) either in a resistant/anxiously or an avoidantly attached way (R). Resistant or anxiously attached responses are reinforced (Sr) by the immediate avoidance or reduction of feelings of
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loneliness (which has motivational priority for these children; Cassidy, 1994) (-S- or ° S-), but come at the expense of increased distress-levels related to children’s heightened focus on negative emotions (Brumariu, 2015) and related to the fact that proximity and support elicits fear for pain due to the attachment figure’s inconsistent availability (Main, Kaplan, & Cassidy, 1985) (+S-). Finally, these responses often lead to the long-term deterioration of the relationship (Cassidy, 1994; Mikulincer & Shaver, 2007). Lisa’s case provides illustrations of resistant and anxious coping behaviors. For example, during the hospitalization after her second suicide attempt, she had frequent phone calls with mother and she was very eager for her mother’s visits. She literally stood waiting at the door for her mother to enter. However, as soon as mother arrived and started asking questions about how Lisa was doing, she refused to give answers (“I do not know” or “Bad, I guess”), expressing anger and annoyance towards mother, which eventually elicited a fight with mother. This fight could last an entire visit, until, at the end of the visit, Lisa started saying how much she loved her mother and how much she hoped her mother would come back for another visit. This behaviour reflected Lisa’s bid and longing for support and closeness with mother, but also showed how mother’s response to that bid induced new distress, which activated Lisa’s fear for new relational ruptures and her anger about past ruptures. This in turn elicited new child behaviour that had a further damaging effect on the mother-child relationship. Avoidantly attached responses are reinforced (Sr) by the avoidance or reduction of distress about the relationship (e.g., about possible new rejection) and the avoidance or reduction of situational distress. However, it makes children more vulnerable for the maladaptive effect of distress that results from enduring unresolved problematic situations. John’s case provides illustrations of avoidant coping behaviours. After several episodes during which mother left the small children alone in the house after having verbally abused John, John decided that he never wanted to feel so anxious, guilty, and vulnerable any more. So he started rejecting mother, trying to avoid having any contact with her. However, the sister was a constant reminder of the painful emotions experienced in interaction with mother.
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Moreover, John was afraid that his sister would start talking about these events in the care unit and would start blaming him for the conflicts with mother. To avoid his sister from talking, he belittled or insulted her every time she tried to speak in group. This gave him a sense of control, but resulted in the constant fights with sister that were cause for the referral to therapy. This behaviour reflected John’s attempts to avoid being exposed to the negative emotions experienced during interactions with mother. By belittling and insulting his sister when she tried to speak to others in the unit, he prevented her from saying anything hurtful. Although this strategy had an immediate relieving effect, on the long term, it had a negative effect on his relationships with his sister, the unit’s staff, and peers. Regarding the assessment of attachment and ruptures in attachment relationships, different instruments (interviews, questionnaires, observation procedures) have been developed. However, most of these instruments are mainly used in research and less is known about their value in clinical practice. In infancy, observation instruments are best validated (Waters, Bosmans et al., 2015). After infancy, attachment interviews like the Adult/Adolescent/Child Attachment Interview have been regarded as a golden standard, but they have been criticised for being expensive, time-consuming, and conceptually controversial (Waters, Bosmans et al., 2015). An alternative are questionnaires. They are easy to administer and highly reliable. While insecure attachment scores on the questionnaires are of high clinical relevance, the validity of high secure attachment scores can be more problematic (Bosmans & Kerns, 2015). As shown above, in this case, at least the stability of secure scores over time needs to be considered (Bosmans, Van de Walle et al., 2014). The abovementioned SBS assessment procedure is a promising new avenue to conduct attachment assessment. The test is easy to administer and easy to score, but its clinical value has not yet been directly studied. For these reasons, the current guideline continues to suggest that it is best practice to add clinical observation and clinical interview to assess secure versus insecure attachment (Crowell, 2003). For both clinical observation and interview, the core focus should be on
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whether or not children seek parental support during distress and whether support seeking leads to relief and puts the child back on track in terms of normative exploration and development (Crowell, 2003). Clinical interviews can be organized in a similar fashion as the downward arrow technique that is used to assess cognitive scripts (e.g., Leahy, 2003). For example, in an interview with an adolescent, a therapist might ask: “If you have a problem, do you have the feeling that you can go to your parents/caregiver for help” If the adolescent does not easily seek proximity and support, the therapist might ask “what keeps you from going to your mother/father/…”. If the adolescent easily seeks support, the therapist might ask “can you give an example? Did it make you feel better?” If the adolescent has the impression that support seeking is not effective, the therapist can ask “can you explain why you feel that going to your mother/father is not helpful?”. In both scenarios, the therapist can continue asking about the emotions and interpretations related to the lack of (sensitive) care until the child reveals core insecure attachment themes (Johnson, 2008). For a more elaborated description of an effective clinical interview (see also Diamond et al., 2014). Adding attachment-focused intervention strategies to traditional CBT treatment programs Finally, based on the above review, it seems reasonable to argue that for insecurely attached children, the effect of existing CBT treatment strategies might be significantly increased if therapists first try to help repair existing attachment ruptures. To date, most attachment-psychopathology research is correlational by nature. So, little research allows to directly derive the prevalence of attachment problems in children and adolescents with emotional and behavioural problems (see Madigan et al., in press). This makes it hard to predict for how many children and adolescents such an addition could be important. However, a comprehensive meta-analysis on these associations shows moderate to high effect sizes (Madigan et al., in press), suggesting that repairing attachment ruptures could be relevant for a relevant number of children.
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In order to develop strategies to repair attachment ruptures, it seems useful to learn from ABFT. Although it was argued above that more research will be needed to establish the evidence base status of ABFT, this therapy’s large effect sizes could mean that it consists of a useful strategy to repair children and adolescent’s trust in their parents’ support. In what follows, three core elements of this strategy will be described in more detail, to give an impression of what might be needed to achieve repair: (1) identify attachment ruptures, (2) identify children and parents’ desire for relationship repair, and (3) help children share ruptures with parents and (4) help parents respond in a supportive way. To identify attachment ruptures, family conversations are needed that direct the focus away from the child’s problem (e.g., depression or suicidality) towards the relationship with the parents (e.g., “if you feel so bad that you eventually try to kill yourself, why don’t you go talk about it with your parent?”). This shifts the conversation towards reasons why the child does not want to go to the parents (e.g., “my mother says I should get my act together me when I say I feel sad”), which are indications of attachment ruptures. This creates the opportunity to identify desire for relationship repair. Such conversational topics typically first elicit parents’ and children’s defensive emotions like anger that express mutual blame for the current (relational) turmoil (e.g., mother: “you don’t want my help, you just try to manipulate me”; child: “you never listen to me, you only think about yourself”). However, anger and blame are often defensive reactions aimed to protect the underlying vulnerable (attachmentrelated) feelings of pain, rejection, and loneliness (Johnson, 2008). So, a therapist can use these emotions to help the family talk about the vulnerable emotions instead of the defensive emotions (e.g., the child is afraid that he/she is not important for mother and the mother is afraid that her son does not love her). This way, the therapist shows that the negative family interactions reflect each member’s desire to be closer, which can motivate them to work on relationship repair. This can be achieved in one session (Diamond et al., 2014). To help children share ruptures with parents, one approach is to briefly work with children separately. During these sessions (feasible in one to three sessions) the therapist
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identifies past painful interpersonal experiences and motivates the child to share these experiences during a conversation with the parent (Diamond et al., 2014). To help parents respond in a supportive way to the child’s disclosure during this conversation, the therapist can organize a small number of separate sessions parallel with the parents alone. During the latter sessions (again one to three sessions can suffice), the therapist can prepare the parents for this conversation. First, parents need to be motivated to respond supportive to the child’s disclosure. Then, parents can be trained to validate the experiences of the child without responding defensively. Within ABFT, this has been called training parents’ emotion coping skills (Diamond et al., 2014). Afterwards, parents and their child get back together to talk about the ruptures and to provide support to the child. The number of sessions needed to discuss attachment ruptures depends on the number of severe ruptures the adolescent feels that are needed to share (Diamond et al., 2014). Finally, strategies are needed to generalize these newly acquired conversational and support skills to the home environment. Within ABFT, this is done by adding sessions during which parents and children need to use their new skills to discuss themes of discord or children’s requests for autonomy or children’s areas of (often depression-related) distress (Diamond et al., 2014). However, it seems reasonable to assume that parents might need more training to be able to continue providing sensitive and responsive care in the absence of the therapists’ support. For this, it might be interesting to turn to insights from early attachment interventions (like PCIT) to remain consistently supportive and to reduce the risk that insecure schemas are reactivated. Although it makes sense to design attachment-focused intervention strategies based on already known promising practices such as ABFT, much more work is needed. First, the effect of ABFT’s modus operandi is best evaluated for depression and suicidal ideation. Based on the argument that insecure attachment is a transdiagnostic risk factor, it might be expected that this strategy should work for other problems as well. Thus far, there is some evidence suggesting that ABFT can be meaningfully applied to anxiety problems (e.g.,
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Siqueland, Rynn, & Diamond, 2005). Nevertheless, for other problems such as externalizing behavior problems, it could prove necessary to adjust this approach to the specific characteristics of each unique problem. Second, ABFT is developed to treat adolescents, so treatment development work is needed for other age-groups such as middle childhood. Moreover, although beyond the scope of the current review, the question can be asked whether also CBT treatment of young adults and older adults could benefit from including age-appropriate attachment-focused intervention components. The results of Levy et al. (2011) do indeed suggest that such an addition could be useful. Finally, and most importantly, the final goal needs to be to investigate whether the attachment-CBT combination indeed significantly increases treatment effects. Concluding remarks The above research does seem to provide important arguments that for insecurely attached children, it could be valuable to broaden child and adolescent CBT treatment by including the restoration of children’s ruptured trust in parental availability for support as novel treatment goal. Moreover, this review gave some first suggestions as to what would be required to restore these ruptures. It seems necessary that the therapist simultaneously works with (1) the child/adolescents’ information processing biases and attachment expectations and with (2) the parents’ skills to provide sensitive support for the child’s experienced attachment ruptures. It seems reasonable to argue such an intervention can be easily integrated with the existing effective CBT interventions that are developed to treat cognitive vulnerabilities, to enhance adaptive skills, and to solve the cognitive scars that constitute the vulnerability for relapse. This way, the current review does provide knowledge and arguments that could be useful for the everyday clinical practice of child and adolescent CBT therapists.
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Acknowledgement This research was supported by Grants G.0934.12 and G.0774.15 of the Research Foundation Flanders (FWO), Grants OT/12/043 and CREA/12/004 from the Research Fund KULeuven, Belgium. The author would like to thank Laurence Claes for her extensive feedback on different versions of the manuscript.
Footnotes 1
To ensure anonymity of patients, none of the cases reflect actual patients. The examples are
drawn from clinical practice, but altered and combined in the two currently presented cases to provide readers with clinically relevant illustrations of the theory.
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Table 1 Sample Prompt Word Outline and Stories – Middle Childhood Script Assessment At the Beach Mom and I
climb
mom
bandage
picnic
rocks
hurry
hug
beach
I’m cut
doctor
home
High Script Story – child seeks mom (secure base) when injured, she responds quickly, child is feeling better and appreciates mom’s help, mom hugs the child and they go home, back on track. One day, my mom and I decided that it was the perfect day for a picnic at the beach. We lived on the west coast of California and there were many, many beaches there. As I saw a crop of rocks in the distance, I wanted to climb it, so me and my mom ran over eagerly. As I was climbing the tallest, biggest rock, I felt a stinging pain in my left finger. I was very scared and then my fear increased as I looked down and saw the rocks smeared with blood and my finger somewhat mangled. I ran over to my mom, nearly in tears, and she rushed me over to the hospital, where a doctor gave me stitches and put a bandage on it to keep it from getting infected. I appreciated my mom for that very much as she relieved the pain and helped me when I needed it. After that, she gave me a hug, and we went home. Low Script Story – no secure base script, mom fails to respond quickly, child reacts to mom’s hug by saying it didn’t make anything feel better Mom and I decided to have a picnic at the beach. When we started to climb the rocks, even though it was really fun, I cut my foot on a really sharp rock. I told my mom to hurry to the doctor, but I don’t think she heard me in time, because all the
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blood was just coming out. It really scared me, I almost fainted. When we got to the doctor, he put a bandage on it and my mom gave me a hug, but that didn’t make it feel any better, and then we went home.
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Figure 1: Attachment and Adaptive Development
Experiences of Sensitive Parental Care
Exploration Attachment Development
Support Seeking Stress
Adaptive Development
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Figure 2: Stages in Attachment Development over the Life-Span
Note: AF = Attachment Figure
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Figure 3: Classical Conditioning Secure Attachment CS Sensitive parent
UCS
UCR
CR
Care during distress
Relief
Trust
Insecure Attachment CS Insensitive parent
UCS
UCR
CR
Rejection
Continuing distress/
No trust
during distress
dissapointment/frustration
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CBT and Attachment
Figure 4: Operant conditioning Secure Attachment Sd
.
Distress
R Care Seeking
Trust
Sr °Sr-; -Sr-: distress is avoided or reduced +Sr+: sense of security and love
Insecure Attachment Sd Distress
.
R Anxious
Distrust
Sr °Sr-; -Sr- : loneliness avoided or reduced +Sr-: distress increases (hyperactivating ER)
Avoidant
°Sr-; -Sr-: distress about relationship is avoided or reduced °Sr-: -Sr- : distress is avoided or reduced °Sr+ : any distress that occurs in spite of the deactivating ER strategy cannot be solved
