Since the early 1970s, Sroufe, Egeland, Carlson, Collins and others have been following a large cohort of children from the sixth month of the mother’s pregnancy through to the present. Eighty-five percent of the 212 at 24 months are still in the study close to three decades later. Early losses occurred before the decision was made to change the initial shorter study (started by Egeland, a psychologist, and Deinard, a pediatrician) to a longitudinal study. The authors noted that the losses were in the most high stress and unstable of the families.

The families were chosen intentionally to include caregivers who may present parenting difficulties by selecting first born children to mothers who qualified for public assistance for prenatal care and delivery. Poverty was the marker that would ensure this. They were careful to note that these mothers had a wide variety of backgrounds and degrees of support available, thus also ensuring a wide range of outcomes 28 years later (the age now under study).

The authors started with an excellent overview of the challenges faced, the key claims and guide to the book, conceptual and theoretical supports, organizing perspective and assessments. Understanding the frequency, breadth and depth of the assessments with over 10,000 resultant variables is crucial to giving credence to the resulting conclusions. The strength of this work comes not just from the lessons learned about development, change and continuity but from the impressive evidence that places the lessons on a firm foundation and the even more fascinating predictability about development that emerged from the data.

Throughout the book, it is easily possible to pull out sentences that may have made intuitive clinical sense but are now backed up with statistics (kept to an appropriate minimum since background papers are well-referenced). For instance: by heightening and chronically emitting signals of need toward an only intermittently responsive caregiver, a resistant attachment organization is established which is correlated with anxiety disorders at age 17½. By minimizing signals of need that may further alienate rejecting caregivers, an avoidant attachment organization is established which shows a connection to externalizing behavioural disorders through early childhood and adolescence. Anxious attachment in general, with no distinction between avoidance and resistance, was associated with depression. There are remarkable parallels between how mothers responded to tasks with their children at 24 months and the same children more than 20 years later, responding to their own 24-month-old children.

Other conclusions have implications for prevention and intervention. In breaking the cycle of abuse, three relationship factors were most helpful for the mothers: (1) receiving emotional support from an alternative non-abusive adult, therapy experience of at least six months, supportive and satisfying relationship with a mate; (2) ability to predict high school dropping out with 77% accuracy using only quality of care measures up to age 42 months; (3) boundary violators during middle childhood were less competent in dealing with mixed gender relationships during adolescence and were more likely to have mothers who were abused.

As interesting as any individual observation or prediction may have been, it is the general observations and conclusions about development that pull the work together and provide a framework that will be useful to clinicians, program planners and researchers for years to come. They include implications for classification systems such as the Diagnostic and Statistical Manual, for treatment of specific disorders and for prevention and early intervention services. Above all, they have demonstrated that development is a lawful, understandable and predictable process when there have been multiple methods of assessment from multiple independent sources.

This is a book that I wish was written and that I had read as a resident. It’s not that there weren’t books about development, but they were based on the wisdom of clinical observation by gifted clinicians after years of work. What this group has contributed is the research basis for development, and in the process have given it a much more interactive and dynamic life than theory and clinicians have been able to do. They shift us from traits to interactions, from today’s preoccupation with genetics to the psychosocial environment, from blaming parents to acceptance of their unique histories and pasts, and, more importantly, from the unpredictable to the predictable.

Some time ago, when giving an invited talk about personality disorder from the perspective of a child and adolescent psychiatrist, I ended with the thought that we may be training our residents from the wrong end of life. They start out in the world of adult psychiatry and work backwards gradually. My thought was that we needed to start with infancy and the attachment process, then work forward into childhood, adolescence and adulthood. This book has shifted my ‘clinical’ thought into a research base. If we understood the results of this book and the developmental process and predictability, we would practice a more researched based therapy with each growing stage of life.

This book represents the summary of a lifetime dedication by many researchers to the mental health and well-being of children and youth and makes this dedication available to all of us who work with and care about children and youth in society. They deserve not only our thanks, but more importantly, our attention.

Now that the work has been done, the book has been written, it is time for you to read it and then recommend it to every psychiatry resident beginning their career.

The Development of the Person: The Minnesota Study of Risk and Adaptation from Birth to Adulthood

In this article, we describe the results of the second phase of a randomized controlled trial of Minding the Baby (MTB), an interdisciplinary reflective parenting intervention for infants and their families. Young first-time mothers living in underserved, poor, urban communities received intensive home visiting services from a nurse and social worker team for 27 months, from pregnancy to the child's second birthday. Results indicate that MTB mothers' levels of reflective functioning was more likely to increase over the course of the intervention than were those of control group mothers. Likewise, infants in the MTB group were significantly more likely to be securely attached, and significantly less likely to be disorganized, than infants in the control group. We discuss our findings in terms of their contribution to understanding the impacts and import of intensive intervention with vulnerable families during the earliest stages of parenthood in preventing the intergenerational transmission of disrupted relationships and insecure attachment.

Minding the Baby®: Enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program.

Controversy about dissociation and the dissociative disorders (DD) has existed since the beginning of modern psychiatry and psychology. Even among professionals, beliefs about dissociation/DD often are not based on the scientific literature. Multiple lines of evidence support a powerful relationship between dissociation/DD and psychological trauma, especially cumulative and/or early life trauma. Skeptics counter that dissociation produces fantasies of trauma, and that DD are artefactual conditions produced by iatrogenesis and/or socio-cultural factors. Almost no research or clinical data support this view. DD are common in general and clinical populations and represent a major underserved population with a substantial risk for suicidal and self-destructive behavior. Prospective treatment outcome studies of severely ill DD patients show significant improvement in symptoms including suicidal/self-destructive behaviors, with reductions in treatment cost. A major public health effort is needed to raise awareness about dissociation/DD, including educational efforts in all mental health training programs and increased funding for research.

/pdf/dissociation-debates-everything-you-know-is-wrong-2xlwkbon33.pdf

Dissociation debates: everything you know is wrong.

Migration is a critical issue for child development in the 21st century. We expand on Garcia Coll et al.'s (1996) integrative model of minority child development by drawing from principles of attachment theory and interpersonal relationships research to offer new insights into how youth manage and respond to migration experiences. Immigrant and refugee youth should experience better outcomes to the extent that they (a) maintain strong relationships with caregivers and peers who provide a sense of closeness, safety, and confidence during the process of adjusting to this life transition and (b) find ways to establish a sense of connection and belonging to the new people, places, communities, and social networks within which they now live. Strong bonds to people and connection to places (both familiar and new) can counter the social stratification consequences to minority youth development that are well articulated in Garcia Coll et al.'s integrative model. The need for new and better strategies that promote the positive development of immigrant and refugee youth within their families, schools, workplaces, and communities is crucial, not only for individuals and families but for society as a whole. (PsycINFO Database Record

Using attachment and relational perspectives to understand adaptation and resilience among immigrant and refugee youth.

Epidemiological, clinical and neurobiological studies of the last 30 years suggest that traumatic attachments during the early years of life (developmental trauma) cause a specific vulnerability to psychopathological developments based on dissociative pathogenic processes that interferes … Dissociative processes are manifested in various symptoms: arousal dysregulation, dissociative detachment (dissociation of consciousness: e.g. depersonalization), dissociative compartmentalization (dissociation among ego states), somatoform symptoms (somatoform dissociation), emotional and behavioral regulation difficulties and severe interpersonal problems. In adult clinical populations dissociative processes and the related symptoms may either contribute to the genesis of well-defined disorders such as dissociative, borderline and complex post-traumatic, or variably occur in many other DSM or ICD diagnostic categories complicating their clinical pictures and worsening the prognosis. The clinical complexity of developmental trauma requires specific training to enable mental health professionals to recognize the signs of traumatic developments and to implement specific treatment strategies. Besides an introductory overview of the literature on clinical problems and treatment strategies for the sequels in adulthood of developmental trauma, this paper offers an outline on three issues on the adult outcome of developmental trauma and its therapy: the role of disorganized attachment, the need to distinguish disintegrative and dissociative pathogenic processes and the usefulness of traumatic-dissociative psychopathological dimension for clinical reasoning of the contributions of attachment theory and research to the developmental psychopathology of adult disorders related to cumulative traumas in childhood.

/pdf/the-role-of-attachment-trauma-and-disintegrative-pathogenic-w8ph0yubr8.pdf

The Role of Attachment Trauma and Disintegrative Pathogenic Processes in the Traumatic-Dissociative Dimension.

Disorganized/Disoriented (D) attachment has seen widespread interest from policy makers, practitioners, and clinicians in recent years. However, some of this interest seems to have been based on some false assumptions that (1) attachment measures can be used as definitive assessments of the individual in forensic/child protection settings and that disorganized attachment (2) reliably indicates child maltreatment, (3) is a strong predictor of pathology, and (4) represents a fixed or static “trait” of the child, impervious to development or help. This paper summarizes the evidence showing that these four assumptions are false and misleading. The paper reviews what is known about disorganized infant attachment and clarifies the implications of the classification for clinical and welfare practice with children. In particular, the difference between disorganized attachment and attachment disorder is examined, and a strong case is made for the value of attachment theory for supportive work with families and for the development and evaluation of evidence-based caregiving interventions.

/pdf/disorganized-attachment-in-infancy-a-review-of-the-1vcufo8q0m.pdf

Robert Weigand

Papers

Disorganized attachment in infancy : a review of the phenomenon and its implications for clinicians and policy-makers