**2. Attachment theory: Key concepts**

Studies in attachment have consistently shown the undisputed role of attachment in child development. In particular, studies have repeatedly demonstrated that the quality of child attachment to parent is one of the best indicators of the child's mental health and later adaptation [3,4]. All children, with some rare exceptions, develop an attachment relationship with their caregiver and view this figure, even if inadequate, negligent or abusive, as a potential source of comfort in stressful situations. The display of attachment behaviors by the child stems from a biologically driven system in which the child is dependent on the caregiver's responsiveness to their needs to ensure survival. As such, the child's capacity to form a bond with a caregiver does not depend on the type of care received. What varies among children is the quality of the attachment relationship developed towards the caregiver, i.e. the degree of trust the child has towards the caregiver's emotional availability, ability to protect, comfort and soothe in distressing situations. According to attachment theory and empirical studies, individual differences in child attachment behaviors are primarily based on two types of factors. The first, proximal to the child, is quality of caregiving, while the second is made up of more distal variables likely to affect parental care, such as the parent's own state of mind in relation to past attachment experiences.

#### *Quality of caregiving*

#### *Parental sensitivity and attachment security*

Child attachment pattern to parent is closely linked to the latter's sensitivity, i.e. the parent's capacity to detect, interpret, and respond appropriately and within a reasonable delay to the child's needs and signals [5,6]. Based on interaction experiences with a sensitive parent, children learn, as early as 12 months of age, that their parental figure will help appease their distress in stressful situations [7].Accordingly, by the end of their first year of life, children will be inclined to seek parental proximity in stressful situations to regulate emotions and organize behaviors and, once comforted, to use their parental figure as a secure base from which to explore [6].

64 Child Abuse and Neglect – A Multidimensional Approach

development than more distant variables such as poverty or parents' psychological state of mind. Therefore, based on this model, parent-child interactions and child attachment to parent act as relational mediating processes between distal systemic variables and child adaptation,

The objective of this chapter is to present attachment theory as a useful framework for assessing and promoting parental competency in child protection cases. In the first section of this chapter, we present key concepts of attachment theory, which are at the heart of all attachment-based clinical protocols. In the second section, the two main attachment-based intervention models are discussed: 1) the long-term model which addresses parents' representations of attachment relationships, and 2) the short-term model which uses videofeedback to modify inadequate parental behavior. In addition to describing these intervention models, this section provides a review of studies having tested the efficacy of these protocols with parents and children reported for child maltreatment. In the third and final section, we present how a short-term attachment-based intervention protocol may be used

Studies in attachment have consistently shown the undisputed role of attachment in child development. In particular, studies have repeatedly demonstrated that the quality of child attachment to parent is one of the best indicators of the child's mental health and later adaptation [3,4]. All children, with some rare exceptions, develop an attachment relationship with their caregiver and view this figure, even if inadequate, negligent or abusive, as a potential source of comfort in stressful situations. The display of attachment behaviors by the child stems from a biologically driven system in which the child is dependent on the caregiver's responsiveness to their needs to ensure survival. As such, the child's capacity to form a bond with a caregiver does not depend on the type of care received. What varies among children is the quality of the attachment relationship developed towards the caregiver, i.e. the degree of trust the child has towards the caregiver's emotional availability, ability to protect, comfort and soothe in distressing situations. According to attachment theory and empirical studies, individual differences in child attachment behaviors are primarily based on two types of factors. The first, proximal to the child, is quality of caregiving, while the second is made up of more distal variables likely to affect parental care, such as the parent's

Child attachment pattern to parent is closely linked to the latter's sensitivity, i.e. the parent's capacity to detect, interpret, and respond appropriately and within a reasonable delay to the child's needs and signals [5,6]. Based on interaction experiences with a sensitive parent, children learn, as early as 12 months of age, that their parental figure will help appease their distress in stressful situations [7].Accordingly, by the end of their first year of life, children

and thus become primary interventional targets for promoting child development.

in the assessment of parental capacity in child protection cases.

own state of mind in relation to past attachment experiences.

*Quality of caregiving* 

*Parental sensitivity and attachment security* 

**2. Attachment theory: Key concepts** 

Alternatively, an insensitive parent, who misinterprets or fails to respond to child signals, encourages the development of insecure child attachment patterns. More specifically, following repeated experiences with a rejecting or distant parent, the child is more inclined to develop an insecure-avoidant attachment pattern, characterized by the minimization of distress signals and proximity-seeking behaviors in order to suppress the activation of negative emotions, which are difficult for the parent to manage. In response to more inconsistent parental behaviors (sometimes sensitive, sometimes insensitive), the child is likely to develop an insecure-ambivalent attachment pattern. This attachment pattern is characterized by an exaggeration of distress signals and proximity-seeking behaviors by the child towards the attachment figure in order to maximize chances of receiving parental comfort. However, resistant behaviors with respect to physical contact and parental comfort are also characteristic of this attachment pattern, resulting from the child's anger towards the parents' inconsistency. While the distress of avoidant and ambivalent children may not be adequately appeased, these children still manage to develop an attachment strategy that organizes behaviors and emotions towards the attachment figure in situations of stress.

#### *Parental frightening/frightened behavior or extreme insensitivity and disorganized child attachment*

While some children with an insecure attachment develop organized strategies to access the attachment figure when distressed, others show a breakdown of attachment strategies or fail to develop coherent approach strategies to gain access to the parent. In the presence of their attachment figure, these children exhibit confused and disoriented behaviors, and may even display frightened facial expressions or body postures. This particular group of children are identified as presenting insecure disorganized attachment behaviors. Recent studies have shown that mothers who demonstrate frightening or frightened behaviors during interactions with their child (e.g. intense withdrawal, hostility, momentary state of dissociation, facial expression of fear, hypervigilance, predatory behavior, sexualized or deferential) are likely to promote the development of insecure disorganized attachment behaviors in their children [8-10]. At the communication level, research has also showed that mothers of disorganized preschooler tend to utter frightening remarks and ridicule their child [11]. As Hesse [12] stated, children showing disorganized attachment behaviors are caught in an unsolvable paradox: their potential source of comfort is also their source of fear [13]. Disorganized children are therefore less likely to adequately explore their environment, for their attachment system is chronically activated by feelings of fear or apprehension caused by the presence of their attachment figure [14].

Disorganized attachment is the type of attachment most strongly linked in childhood to socio-emotional adaptation difficulties, cognitive deficits, psychopathology, low self-esteem, as well as psychopathology in adolescence and adulthood, including anxiety disorders, dissociation, and suicidal thoughts [3,15-20]. Studies have also showed that attachment

disorganization is maintained over time and evolves into a controlling strategy at the beginning of school age, where children becomes aggressive and punitive towards their parent, or on the contrary, answer the affective needs of the latter [21,22]. This parent-child rolereversal phenomenon, commonly called "parentification", has often been observed in parent and maltreated-child dyads [23].

Attachment Theory in the Assessment and Promotion of Parental Competency in Child Protection Cases 67

developing unresolved attachment representations. When painful experiences remain unresolved, they continue to exert an (unconscious) influence on the parent's psychological processes and behaviors, inhibiting the parent'sability to properly perceive, interpret and adequately respond to the child's needs and signals and thus contributing to the emergence

Several studies have demonstrated the mediating role of maternal sensitivity in the transmission of attachment from parent to child [32]. Another study of high-risk dyads identified the role of frightening parental behaviors in the transmission of disorganization [27]. Although studies having identified precursors to attachment disorganization in maltreated children are scarce, findings stemming from the field of attachment support the need to develop intervention protocols aiming improvements in parental sensitivity in order

**3. Attachment-based intervention strategies and protocols designed for** 

Based on Bowlby's [34] work and empirical studies on the intergenerational transmission of attachment, Berlin et al. [35]suggest that interventions inspired by attachment theory should be guided by three major therapeutic principals. The first two relate to intervention targets and the way change is likely to occur. Attachment-informed interventions are concerned with the promotion of child attachment security because it constitutes an important protective factor in the development and well-being of the child. Therefore, key targets should be empirically associated with child attachment. Whether target of intervention is to change parents' representations of attachment or behaviors with the child, in both cases, emphasis is placed on the parent-child attachment which is used as the main intervention vehicule to promote child attachment security and optimize child development. The third principal refers to the intervention process in which a relationship of trust between parent and practitioner, the latter in the role of a secure base for the parent, is necessary to promote

For the past few years, several intervention protocols have been developed based on research in the area of parent-child relationships and attachment. Accordingly, two metaanalytic studies [33,36] have shown that short-term behavioral interventions aimed at changing parental behavior towards the child are more effective in improving parental sensitivity and child attachment security and reducing the incidence of disorganized attachment behaviors, than those aimed at changing parental representations or providing parental social support. However, none of the studies included in these meta-analyses exclusively examined maltreating parents and their children. Recently, three majorattachment-based intervention protocols have emerged as effective for improving child attachment security of maltreated children. These protocols, which are either shortterm (approximately 6-10 weeks) or long-term (approximately 20 weeks to 2 years), have been developed for mother-child dyads in infancy and preschool age, and usually involve weekly home visits. Long-term protocols aim mainly the modification of parents'

and maintenance of insecure disorganized attachment behaviors in the child.

to promote attachment security and reduce attachment disorganization [33].

**maltreated children and their parents** 

change.

Given that abusive and neglecting behaviors of maltreating parents are highly frightening for children, it is not surprising to find that the majority of maltreated children exhibit disorganized attachment behaviors, i.e., up to 86% are classified as insecure disorganized children according to various studies [20,24]. In particular, a model by Main and Hesse [25] propose that parents who have not been able to resolve past traumas from their own childhood (abuse, loss) are likely to show short moments of dissociation, such as sudden lapses with reality [26], altering their behavior when interacting with their child, which may activate the child's fear and attachment systems. In support of this hypothesis, a recent study with a high-risk population has shown the mediating role of frightening parental behaviors in the transmission of unresolved parent attachment representations (unresolved loss or experience of abuse) to the child showing disorganized attachment behaviors[27]. A second model,articulated by Lyons-Ruth et al. [8], suggests that it is the parent's inability to regulate thechild's physiological and emotional states that contributes to the child's development of a disorganized attachment. In other words, the inability to face potentially traumatizing events hinders the parent's capacity to regulate the child's own physiological experience of fear[28].Hence, parents of disorganized children fail to repair situations that elicit fear in their child. Instead of being sensitive following a frightening situation for the child, these parents remain helpless or show hostility[8]. Through these extreme insensitive behaviors, parents do not appease their child's fear and attachment systems, but instead actually exacerbate stress and become themselves an important source of fear for the child.

#### *Parental state of mind with regards to attachment*

Parental state of mind with regards to attachment refers to the representations of attachment relationships and cognitive strategiesparents have developed since childhoodto organize and understand present and past attachment experiences. Parental attachment state of mind is an important precursor of child disorganized attachment as it is likely to interfere with parental sensitivity. Notably, studies have demonstrated thatmothers of children with a secure attachment are more likely to discuss attachment experiences coherently and make metacognitive judgements (e.g. reflective functioning) to reassess the significance and the meaning of past childhood experiences. Conversely, mothers of children with insecure disorganized attachment are unable to solve past traumatic experiences (e.g. abuse, loss) [29- 30]. Their discourse has shown to be incoherent when describing past traumatic events and related emotionsas well as sometimes disconnected from reality.

Abusive and neglectful parents are definitely at-risk of developing unresolved attachment representations. Indeed, many of them have suffered sexual or physical abuse, or have been abandoned and placed in foster homes in their childhood [1,31]. The personal background of these parents, all too often filled with traumatic events, clearly puts them at risk of developing unresolved attachment representations. When painful experiences remain unresolved, they continue to exert an (unconscious) influence on the parent's psychological processes and behaviors, inhibiting the parent'sability to properly perceive, interpret and adequately respond to the child's needs and signals and thus contributing to the emergence and maintenance of insecure disorganized attachment behaviors in the child.

66 Child Abuse and Neglect – A Multidimensional Approach

*Parental state of mind with regards to attachment* 

related emotionsas well as sometimes disconnected from reality.

and maltreated-child dyads [23].

disorganization is maintained over time and evolves into a controlling strategy at the beginning of school age, where children becomes aggressive and punitive towards their parent, or on the contrary, answer the affective needs of the latter [21,22]. This parent-child rolereversal phenomenon, commonly called "parentification", has often been observed in parent

Given that abusive and neglecting behaviors of maltreating parents are highly frightening for children, it is not surprising to find that the majority of maltreated children exhibit disorganized attachment behaviors, i.e., up to 86% are classified as insecure disorganized children according to various studies [20,24]. In particular, a model by Main and Hesse [25] propose that parents who have not been able to resolve past traumas from their own childhood (abuse, loss) are likely to show short moments of dissociation, such as sudden lapses with reality [26], altering their behavior when interacting with their child, which may activate the child's fear and attachment systems. In support of this hypothesis, a recent study with a high-risk population has shown the mediating role of frightening parental behaviors in the transmission of unresolved parent attachment representations (unresolved loss or experience of abuse) to the child showing disorganized attachment behaviors[27]. A second model,articulated by Lyons-Ruth et al. [8], suggests that it is the parent's inability to regulate thechild's physiological and emotional states that contributes to the child's development of a disorganized attachment. In other words, the inability to face potentially traumatizing events hinders the parent's capacity to regulate the child's own physiological experience of fear[28].Hence, parents of disorganized children fail to repair situations that elicit fear in their child. Instead of being sensitive following a frightening situation for the child, these parents remain helpless or show hostility[8]. Through these extreme insensitive behaviors, parents do not appease their child's fear and attachment systems, but instead actually exacerbate stress and become themselves an important source of fear for the child.

Parental state of mind with regards to attachment refers to the representations of attachment relationships and cognitive strategiesparents have developed since childhoodto organize and understand present and past attachment experiences. Parental attachment state of mind is an important precursor of child disorganized attachment as it is likely to interfere with parental sensitivity. Notably, studies have demonstrated thatmothers of children with a secure attachment are more likely to discuss attachment experiences coherently and make metacognitive judgements (e.g. reflective functioning) to reassess the significance and the meaning of past childhood experiences. Conversely, mothers of children with insecure disorganized attachment are unable to solve past traumatic experiences (e.g. abuse, loss) [29- 30]. Their discourse has shown to be incoherent when describing past traumatic events and

Abusive and neglectful parents are definitely at-risk of developing unresolved attachment representations. Indeed, many of them have suffered sexual or physical abuse, or have been abandoned and placed in foster homes in their childhood [1,31]. The personal background of these parents, all too often filled with traumatic events, clearly puts them at risk of Several studies have demonstrated the mediating role of maternal sensitivity in the transmission of attachment from parent to child [32]. Another study of high-risk dyads identified the role of frightening parental behaviors in the transmission of disorganization [27]. Although studies having identified precursors to attachment disorganization in maltreated children are scarce, findings stemming from the field of attachment support the need to develop intervention protocols aiming improvements in parental sensitivity in order to promote attachment security and reduce attachment disorganization [33].
