Week 8 & 9: Attachment + Developmental Disabilities

What are factors of family centered care?

Foster family driven goals

Supports family choices

Respects the cultural individuality within cultures

Targets the child in the context of the family

What are factors of relationship based intervention?

Centers the parent-child relationship as the target of early intervention

Parent-child relationship is the most proximal vehicle for change in a child’s life

What are attachment relationships

Relationships between an infant and their primary caregiver; basis for self-regulation, learning, future relationships, mental health, and emotional well-being throughout lifespan

Who are the founders of attachment theory?

John Bowlby & Mary Ainsworth

Who developed attachment theory?

John Bowlby

Who made attachment theory measureable?

Mary Ainsworth

History of Attachment

1. Requires proximity

2. Not all about nutrition

3. Infants engage in attachment behaviors for safety/survival

4. Consistent across cultures

5. System for developing self-regulation

6. Caregiver sensitivity correlates with attachment

Motor behaviors related to attachment

Sucking, clinging, following, smiling, and crying

Which motor behaviors are most crucial for attachment?

clinging and following

Percentage of Insecure-Avoidant attachment style

15%

Percentage of Secure attachment style

51%

Percentage of Insecure-Ambivalent attachment style

10%

Percentage of Insecure-Disorganized attachment style

24%

How might Insecure-Avoidant show when tested in a strange situation?

• little distress

• little need for closeness or comfort upon reunion

• diminished emotions

What could lead to an Insecure-Avoidant attachment style?

• Caregivers-angry

• Intolerant of distress

• Reject or punish infant for distress

Characteristics of Secure Attachment

• Express distress directly

• Seek comfort from a caregiver without hesitation

• Readily respond to comfort

Characteristics of Ambivalent Attachment

• Show intense distress upon separation

• Respond poorly to caregiver’s attempts to comfort

What could lead to Ambivalent Attachment

Caregivers often misread cues, leading to infant lack of trust

Characteristics of Disorganized attachment

• Less organized patterns than the other styles

• Show contradictory and bizarre behaviors with being re-united, no strategy

• Tend to remain in distress and dis-regulates

• Most predictive of future psychopathology

• Added Ainsworth’s 3 primary attachment categories by Mary Main

What could lead to Disorganized attachment?

Parent who is supposed to be the source of comfort is the source of fear

Infant’s capacity to form attachments

• Form over first year of life

• Infant experiencing severe neglect or lack of caregiver attunement is associated with limits in self-regulation throughout lifespan

What is the development of attachment within the first 6 months?

no obvious preference for one caregiver

What are the key behaviors signaling attachment?

• Show wariness around strangers

• Begin to protest with separation

When do the key behaviors signaling attachment show up?

7-9 months

What are the roles of parents during the development of attachment relationship/self-regulation

• Respond sensitively to infant distress

• Accept children’s emotions

• Communicate openly about emotions

• Scaffold skills in emotional regulation

Development of attachment (neonate)

Cries when dysregulated, regulation is caregiver controlled

Development of attachment (1-6 months)

Begins to co-regulate with caregivers

Development of attachment (7-12 months)

Attachment bond is formed, can begin to self-regulate, but need significant support

• 7 months is peak for attachment to primary caregiver

• 10 months for caregivers outside of primary caregivers

Development of attachment (12-18 months)

Can separate from their caregiver, but need to return often for support (secure base behavior)

Development of attachment (18-36 months)

Can separate for longer periods of time without distress, but continue to return for support when upset

Development of attachment (36-60 months)

May not need to return for support in times of stress

Mothers of preterm infants tend to be

• More intrusive

• Overstimulating

• Less sensitive

• Less affective at calming the infant

• More focused on caretaking versus involved emotionally

Primary parents with depression tend to have

• Lower sensitivity to infant cues

• Challenges with self-regulation

• More harsh and punitive parenting styles

What can maternal depression lead to

Increased chances of childhood depression and anxiety

Down syndrome and attachment

• Attachment relationship formation often is associated with cognitive development

• Attachment may be difficult to measure prior to an infant with cognitive disability achieving 12 month cognitive milestones

How does Autism Spectrum Disorder (ASD) impact development

• 80’s and 90’s - Children with ASD lacked attachments to caregivers

• Parental sensitivity did not correlate with attachment security in children with ASD

Orphanage study findings (Raised in biological families before 33 months)

Age appropriate (motor equivalent of age 8)

Orphanage study findings (Orphanage raised, at least until 33 months)

Motor delay (motor age equivalent of age 6.5)

Orphanage study findings (Overall)

• If exited orphanage between 8-33 months, no significant BOT-2

• Physical therapy intervention for children in institutions until at least age 33 months did not alter their motor development trajectory

Tips from infant mental health

• Build relationships with families and use those relationships as instruments of change

• Always meet with the primary caregiver and child together

• Help the caregiver find pleasure in relationship with child

• Create opportunities for interaction between parent and child

• Remain open, curious, and reflective

What is neurodiversity?

• Pushes back on the deficit based medical model

• Celebrates unique development of each person’s brain

• Autism activism

Why should we adopt the neurodiversity approach opposed to the medical model or social model?

It provides environmental and personal adaptations; promoting language, mobility, and communication

• Curing, normalizing, or masking should not be the goal

What is ableism?

Belief that bodies and minds should be a certain way to be considered normal, particularly in mobility, thought, development, and demeanor.

How are ableist beliefs harmful for neurodivergent people?

Subjects them to attitudes, policies, and practices that communicate they do not belong.

Child/client and caregiver perspective on ableism

Some parents claim that they wish their child didn’t have autism. In reality, you cannot separate the child from the autism; wanting a different child instead

Trends with families with neurodivergent children.

• Typically have less financial security and poorer health

• Neurodivergent children are 2x more likely to experience violence

Intersection of Ableism and Trauma (Alden story)

• Restrict curiosity d/t behavior and outburst

Intersection of Ableism and Racism

• Mislabeling culturally appropriate development as delayed or divergent

• Language vernacular biasing

• Behavior bias of some children as more “dangerous” than others

• Special education and alternative curriculums

What is the medical model of mobility? (neuromaturational model)

• Adult-driven

• Perfect or not at all

• Withhold adaptive equipment

• Wait to see if neurotypical patterns develop

What is the neurodivergent model of mobility? (perception-action)

• Child-driven

• All movement serves the developing nervous system

• Provide adaptive equipment

• Promote independent exploration

Rights of children with disabilities in healthcare

• Best interest is the primary consideration

• Child can listen and participate in decisions about themselves

• Children in need will be provided with mobility aids as early as possible

• Rights of the child with disabilities to live a full and decent life

Describe a new way forward for physical therapists engaging with people with neurodiversity and their support systems

• Explore language

• Reframe thinking and be curious

• Use celebratory framework

• Nothing about us, without us

What is the 5 Level Classification system through self-initiated movement focused on?

• Sitting - trunk control

• Transfers

• Mobility - walking or wheeled mobility

At what age is trauma most impactful towards developing self-regulation?

8 weeks

Childhood trauma sign - Fight

Dysregulated, aggressive attempts to manage, inflexible need for control

Childhood trauma sign in infant/toddlers - Flight

Withdrawn, shutdown, or avoidant

Childhood trauma sign in infant/toddlers - Freeze

Dissociation - often at a great cost later

Childhood trauma sign in infant/toddlers - Fawn

Clingy, solicitous of approval, strong need to caretake of others

What type of trauma is unexpected and can be detrimental to infants?

Pain/medical

Things PTs can do to help

• Be curious

• Provide a safe space/predictable routines

• Confirm words with actions

• Connect behaviors to feelings

• Provide opportunities to regulate emotions

• Inclusive and diverse environment

• Support the caregivers

Helpful treatment techniques with infant challenges

• Work through the caregiver (regulation capacities of attachment, caution with stressed relationship, interpret confusing cues)

• Support caregivers so they can support their infants

• Use close proximity of infant to caregivers

• Introduce over-stimulating movements/positions in a non-stress inducing way