Month: September 2016

Doug Davies, M.S.W., Ph.D., was a beloved colleague, mentor and friend to many in the infant mental health community. He was a Lecturer at the School of Social Work, University of Michigan, had a private practice, and was a MI-AIMH board member for many years. After his retirement from the University of Michigan, he continued to write, provide individual and group reflective supervision, and train infant mental health and early childhood staff in Michigan, Alaska, Virginia and California. His ability to listen deeply helped each of us understand young children, their families, and ourselves better, becoming not only better therapists but better human beings. He provided listening without judgement, genuine compassion, and support that serve as a model we carry within us. We miss him dearly but he was a secure base we have internalized. His felt presence continues with us in our work and in our lives.

A Doug Davies Memorial Lecture was held at The University of Michigan School of Social Work on June 24, 2016.  The following are excerpts from speakers, Julie Ribaudo, LMSW, IMH E®, and John Bennett, LMSW,  given at that memorial. John and Julie offered personal comments about Doug, and Julie shared the beginning of a chapter written by Doug in the days preceding his death. Doug’s editors at Guilford Press had requested that he write a chapter on toxic stress and one on adolescents for a 4th edition of his text, Child Development (Davies, D. (2011). New York: The Guilford Press). Although initially not sure he wanted to commit the time to write 2 new chapters, Doug agreed, wanting to make complex scientific research easier to understand. He was excited about making information more accessible to clinicians, knowing that a better understanding of complex reactions to trauma would help make better therapists and would ultimately result in better services and outcomes for young children and families impacted by trauma.

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Comments from John Bennett, Doug’s First Clinical Supervisor

“I was Doug’s first Infant Mental Health supervisor, and he was my first supervisee. About a year later, we wrote a paper together: “Intervention and Adaptation in the Third Year: The Mother-Child Dialogue.” That was about 40 years ago. We spent those 40 years as colleagues in the Child Psychiatry Division of the University of Michigan Department of Psychiatry, as office partners in private practice, and, most importantly, as friends. We talked with each other between clients and met once a month for dinner and drinks. We traded stupid jokes, talked about our childhoods and our current lives, our children, and his grandchildren. Unfortunately both of my grandchildren were born in the year following his death, but I’m sure he would have been as happy to listen to those stories as I was his. We regaled each other about being Irish — the random, existential, metaphysical (and somewhat inebriated) views of life lived. We also talked about the new ideas we were discovering — the latest being arousal moderation, brain networks, and metabolic aspects of mental and emotional functioning in childhood, among many others. This would be serious stuff, and then we would get carried away and end up like Moose and Squirrel. It was a great friendship that covered lots of territory. When he retired from the School of Social Work, I was surprised, after hearing all the praise, and how people were not going to be able to get along without him, etc., to hear the Dean end the ceremony by announcing that Doug would continue on doing essentially what he had done prior to his “retirement.” I caught him afterwards and told him how I thought it was such a dirty little Irish trick to say he was retiring, get people to say all those nice things, then go on working just like he’d done before. Doug assured me (with his glinty little Irish wink) that he didn’t know this would happen when he announced his retirement. When he died, and we had the memorial in Kalamazoo, I was hoping he would be hiding off-stage somewhere and come laughing and popping out from behind the curtains just after all the nice things had been said… but not this time. What a nice guy to have as a friend. I still miss him.”

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Julie Ribaudo’s Lecture

“Doug approached his work with intellectual rigor, curiosity, and with a healthy respect for the magnitude of the messages he sought to convey.  Because of that, he often wrote out entire lectures.  While it could stem, on the face of it, boring to be read to (unless you are a young child with an animated parent!), listening to Doug was never boring.  I heard him enough times that he would joke with me that I should leave because I had heard his material before.  I never did and I never regretted it.  It is a great honor and with deep respect for his profound gifts that I am going to read from Doug’s last written contribution to the field of social work and to the lives of children and their families.”

This first section comes from Child Development, 3rd edition. It is included to provide a context for the new text and to show where Doug intended the new information to be placed.*

*Editor’s note

In recent years, the effects of prolonged stress on the [hypothalamus-pituitary-adrenal (HPA)] system has been re-named “toxic stress.” “Toxic stress is the extreme, frequent, or extended activation of the stress response, without the buffering presence of a supportive adult.” Created by ongoing severe environmental stressors such as chronic trauma, abuse, and neglect, “toxic stress” is an internal response to even mild stressors that has been shaped by trauma over time. It is a biological adaptation to frequent experiences of threat and high arousal. “One of the primary consequences of early life toxic stress is HPA dysregulation, as the developing neuroendocrine system is chronically pressed into action.”

The constant secretion of cortisol in response to toxic stress also weakens the immune system. Young children become more susceptible to allergens, which are move prevalent in poverty environments. Young children exposed to toxic stress are much more likely to develop asthma.

Stress Response Systems

The function of biological stress response systems is to secrete hormones and neurotransmitters that provide adaptive responses to external stressors and to modulate internal stress. The limbic system, specifically the amygdala, is responsible for recognizing threat and mobilizing reactions to it; it is the brain’s “alarm system.” When the amygdala signals a threat, the [HPA] system secretes and releases neurohormones called catecholomines, which in turn trigger increases in the amount of cortisol in the bloodstream. Catecholomine release underlies the familiar “fight-or-flight” response, in which the individual’s alertness, concentration, appraisal of the environment, and physical energy intensify in the face of danger.

“Here, I can see Doug looking up, clearing his throat, and ad-libbing just a tad to say, “Here I am thinking of…”  He was always generous in sharing his thinking process with us.”

…When faced with threat, the stress response system focuses brain activity on dealing with the threat and temporarily inhibits other functions. Animal studies have shown that the release of cortisol promotes the freeing of energy, so that the individual can take action, but at the same time suppresses the immune system, physical growth, and emotions and memory. The hippocampus, a brain area that plays a central role in learning and memory, can atrophy if it is bombarded by high concentrations of stress hormones, resulting in memory impairments.

The following section begins Doug’s work on Edition IV.

Epigenetics refers to alterations in the ways genes express themselves in response to changes in biochemical processes. These biochemical changes are in turn caused by environmental influences. The underlying structure of the genes does not change, but their “expression” — the way they regulate functioning — does change. Changes can go in the direction of a well-regulated HPA system when the child receives consistent supportive and protective care by adults; or enduring characteristics of HPA dysregulation, generally in the direction of hyper reactivity, are the likely result of ongoing, unbuffered exposure to toxic stress. When a young child is exposed to toxic stress over time, the constant secretion of the stress hormones cortisol, norepinephrine, and epinephrine leads to epigenetic changes in the HPA system. This is the process underlying over-arousal and reactivity to triggers and mild stressors we observe in chronically-traumatized children.

“Here we see Doug’s sheer brilliance in listening to and probing the meaning of aggressive behavior of young children exposed to violence.  Even before the benefit of brain science to substantiate aggression as often reactive, Doug knew to listen and observe very carefully – with the aim of understanding and helping a child gain distance, psychologically, from what they had endured, and locating the trauma in the past rather than in the present.  Profoundly empathic, he also worked compassionately with parents, teachers, and other professionals to understand the child as well.  He taught the rest of us to do the same.”

To understand  the developmental costs of toxic stress, it is useful to define allostasis, a recent concept that captures the “active process of adaptation” in response to stress.

Allostasis is defined as “maintaining stability through change.” It is “a fundamental process through which organisms actively adjust to both predictable and unpredictable events.” In animals, including humans, allostasis regulates the individual’s ongoing relationship to environmental stress through complex interactions of the nervous, endocrine, and immune systems. In the face of stress or threat — physical or psychological danger, or illness, as examples — these systems work together to promote the best possible adaptation to the environment and survival. In the face of danger, the brain and nervous system appraise the threat and prepare for action, the endocrine system secretes hormones that support action and endurance, and the immune system mobilizes an inflammation response in case of injury.

“Allostatic load,” or overload, refers to how hard these systems have to work to maintain adaptation. In conditions of chronic stress, such as child maltreatment in early childhood, the process of allostasis operates at high levels in order to protect the individual. However, these ongoing mobilizations of regulatory, internally-based protective processes become shaped, or “biologically embedded,” by constantly responding to threat: “When activated chronically and out of context, allostasis ceases to be adaptive and thus may promote disease as maltreated individuals age.” Neurobiological research has shown a number of developmental and health downsides of allostatic overload in early childhood. These include alterations in brain architecture and function. For example, maltreated children as adults show smaller prefrontal cortex volume. The prefrontal cortex houses the brain’s executive functions, including planning, attention, and impulse-control and decision-making. Neuropsychological testing of maltreated, traumatized children shows deficits in all these functions compared to normal children (Beers & De Bellis, 2002) . To the extent that these deficits become embedded, the child’s capacity for learning and flexible responses to the environment will be compromised as development proceeds. The costs of an overactive endocrine system, specifically the HPA axis, have been documented in the biology of trauma literature. Over secretion of cortisol and other stress hormones in response to chronic threat leads to an overactive and more-easily triggered stress response. Behaviorally, this translates to hyperarousal, hypervigilance, overreactions to even minor stressors, and tendencies to “act without thinking” based on fear and anxiety. When the immune system responds to threat by increasing inflammation levels, the body is preparing to fight physical injury. Children and adults with histories of maltreatment show elevated inflammation levels. Increased baseline inflammation levels disrupt the body’s ability to develop acquired immune response and lead to later vulnerability to inflammatory diseases such as rheumatoid arthritis, fibromyalgia, and chronic fatigue syndrome.

To summarize, while early allostatic adaptations to adversity by the nervous, endocrine, and immune systems promote short-term protection and survival, these same adaptations program biological responses in all three systems that are detrimental to development and physical and mental health in the long term.

“Although Doug’s last written words leave us wishing for more, they remind us how much we learned from him. His last writing is a further contribution to his enduring legacy and his capacity to help us strive for excellence and deeper understanding. He knew, and taught us to stay confident too, that through understanding, we would become more compassionate, kinder and better able to support young children and their families. Sometimes we hear sanitized versions of someone when they have died. With Doug, no sugarcoating is needed. He was simply good – through and through.”

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References

Beers, S. R. & De Bellis, M. D. (2002). Neuropsychological function in children with maltreatment-related posttraumatic stress disorder. American Journal of Psychiatry, 159, 483-486.

Danse, A. & McEwen, B. S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology and Behavior, 106, 29-29.

McEwen, B. S. (2012). Brain on stress: How the social environment gets under the skin. Proceedings of the National Academies of Science of the United States of America, 109,  17180-17185.

McEwen, B. S. & Wingfield, J. C. (2003). The concept of allostasis in biology and biomedicine. Hormones and Behavior, 43, 2-15.

Steptoe, A. Hamer, M., & Chida, Y. (2007). The effects of acute psychological stress on circulating inflammatory factors in humans: A review and meta-analysis. Brain, Behavior, and Immunity, 21, 901-912.

Tarullo, A. R. & Gunnar, M. R. (2006). Childhood maltreatment and the developing HPA axis. Hormones and Behavior, 50, 632-639.

This letter, written by Debbie Weatherston and Sheryl Goldberg, was read on behalf of MI-AIMH at the Davies Memorial Lecture.

Doug served the Michigan Association for Infant Mental Health and the infant mental health community throughout his long and distinguished service to children and families. While earning his M.S.W. from the University of Michigan in 1979, Doug received clinical training in infant mental health at the Child Development Project where Selma Fraiberg was the director. That experience shaped his commitment – intellectual and heartfelt – to early experiences, the promotion of social and emotional wellbeing, and the unique developmental and relational approach to health through infant mental health. He began his clinical practice in 1980, combining skills as a gifted mental health professional, supervisor, and faculty member at the University of Michigan.
The Michigan Association for Infant Mental Health – MI-AIMH – benefited from Doug’s extraordinary professional commitments. The organization was so fortunate to have him serve in a leadership capacity for many, many years. Among his most important contributions:

• He played an important leadership role in the development of the MI-AIMH Endorsement for Culturally Sensitive, Relationship-Focused Practice Promoting Infant Mental Health, beginning in 1999. He gave generously of his time and attention to the creation of this work force system that provides a framework for the infant and family field in over 23 states and West Australia.
• He was a mainstay in the development of two Reflective Supervision DVD’s, one (2013) for the infant mental health community and a second (2016) for those working as supervisors or consultants in non-mental health infant and early childhood communities
• He was a member of the MI-AIMH Executive Board of Directors from 2012-2016 where his leadership skills were especially important for participation in the strategic planning process that led to the formal creation of the Alliance for the Advancement of Infant Mental Health, Inc.®.
• He led MI-AIMH in partnering with the Michigan Department of Human Services in 2014 to develop a Joint Policy, Attachment in Infancy and Best Practice Recommendations for Decision-Making for Infants/Toddlers in Foster Care.
• He partnered with MI-AIMH for many years in the development and delivery of training. Of note, in 2013, an important grant-funded training series in the art of Reflective Supervision, “ Building and Expanding Reflective Practice in Infant Mental Health.”

MI-AIMH honored Doug in 2007 with the distinguished Selma Fraiberg Award for his work on behalf of infants, toddlers and families and the promotion of infant mental health. Fitting for him to have been recognized with this award as that is where he began, at the table with Selma Fraiberg and her colleagues.

In sum, Doug’s presence at so many tables enriched the work of MI-AIMH for decades with his intellect, his clinical understanding, his kindness and his compassion. He was revered by all who worked with him – state policy makers, program directors, trainers, supervisors, clinical practitioners, childcare professionals, nurse family partnership professionals, head start, teachers, infant mental health specialists, members and board members, very young children and families.

He was an engaging writer, a deep clinical thinker, generous with his gifts and a beloved mentor to so many in the infant mental health community. We honor him today, with gratitude for his very significant contributions to infants, toddlers and families and each one of us.

Reprinted from The Infant Crier, July-September 2005

John Bowlby described attachment as a fundamental need that has a biological basis. Attachment serves as a protective device for the immature young of many species, including humans. Babies need the care of adults to survive, and they have many built-in behaviors, such as making strong eye contact, cooing and vocalizing, and smiling, that attract adults to them. The primary function of the infant’s attachment behavior is to keep close to a preferred person, in order to maintain a sense of security. When an infant becomes distressed both parent and infant take actions to restore the sense of security. For example, an infant becomes upset and communicates this by looking anxious, crying, or moving closer to her mother. The mother moves towards the baby, soothes her with her voice and picks her up. The baby continues to fuss briefly, then molds to the mother’s body, stops crying and soon begins to breathe more slowly and regularly, indicating a decrease in arousal; her sense of security has been restored. In Bowlby’s terms, the infant’s distress signal, which is functionally an attachment-seeking behavior, activates the mother’s side of the attachment system and the mother takes steps to calm the baby’s distress.

Although the behavioral expression of attachment varies across cultures, attachment is a universal phenomenon in humans. What factors seem to be universal? A baby needs to have an attachment to a primary caregiver (or in many cultures, to a set of primary caregivers). Consistency, sensitivity and contingent responsiveness on the part of the caregivers are essential to the baby’s psychological development. Across cultures, secure-base behavior – the child’s ability to use the caregiver for relief of distress and support for exploration – has been identified as a marker of secure attachment.

How Attachment Develops

Infants make attachments with specific people. Although a newborn may be comforted by anyone who picks her up, she very quickly differentiates her primary attachment figure(s) from others. During the early weeks of life she learns the particular qualities of her mother (assuming the mother is the primary caregiver). Through repeated interactions, she learns to recognize her mother – what her face looks like, what she smells like, what her touch feels like, and how her voice sounds. Through this process the infant’s attachment becomes specific and preferential. In most cultures, infants’ attachments have an order of preference, usually to mother, then father, and then siblings, although infants who are in care full time with a single caregiver often develop an attachment to her that is second only to the mother. Infants and toddlers do form different types of attachment with different caregivers. In cases where a child has an insecure attachment with a mother, a secure attachment with another important caregiver – father, grandparent, or regular child care provider – may take on a compensatory, protective function for the child’s development.

Other Functions of Attachment

In addition to providing a sense of security, the attachment relationship serves other functions that promote the baby’s development.

Regulation of Arousal and Affect

“Arousal” refers to the subjective feeling of being “on alert,” with the accompanying physiological reactions of increased respiration and heartbeat and bodily tension. If arousal intensifies without relief, it begins to feel aversive and the infant becomes distressed. When this happens the infant sends out distress signals and moves toward the caregiver. In a secure attachment the infant is able to draw on the mother for help in regulating distress. The mother’s affective response provides soothing or stimulation to help the infant modulate arousal. Over time, infants and parents develop transactional patterns of mutual regulation to relieve the infant’s states of disequilibrium. Repeated successful mutual regulation of arousal helps the infant develop the ability to regulate arousal through his own efforts. Through the experience of being soothed, the infant internalizes strategies for self-soothing. As development proceeds, good self-regulation helps the child feel competent in controlling distress, negative emotions, and impulses to act out promoting the expression of feelings and communication. By 4-6 months the attachment relationship evolves into a vehicle for sharing positive feelings, and learning to communicate and to play. For example, a 6-month-old infant initiates a game of peek-a-boo (which has been previously taught by her father) by pulling a diaper over her face. Her father responds by saying, “Oh, you want to play, huh?” and pulls the diaper off, saying “peek-a-boo!” and smiling and looking into the baby’s eyes. The baby smiles and begins to wave her arms and kick her feet. The father says warmly, “Oh, you like to play peek-a-boo, don’t you?” The baby vocalizes, then begins to pull the diaper over her face again in order to continue the game. Interactions like this one reveal qualities of attachment relationships that support emotional and cognitive development: mutually-reinforcing, synchronous behaviors on the part of the parent and infant, a high degree of mutual involvement, attunement to each other’s feelings, and attentiveness and empathy on the part of the parent.

A Base for Exploration

From age 1 on, the attachment relationship becomes a base for exploration of the wider environment as well as the child’s developing competencies and her inner world. Attachment theorists consider the motivation to explore and learn about the world and to develop new skills to be as intrinsic in infants as attachment motivation. The confidence with which the child ventures out depends a great deal on her confidence in her attachments. If a toddler has a secure base in her attachment relationship, she will feel free to explore her environment, with the implicit awareness that the caregiver is available if needed.

How Attachment Shapes Future Development

The child gradually develops a working model of attachment based on how he has been cared for and responded to within the attachment relationship. Over the first few years of life, working models become stabilized as expectations of how relationships work, and what one can expect of other people in terms of responsiveness and care. Correspondingly, models of the self in relationships also develop. The young child internalizes assumptions about how effective she is in using relationships, how valued she is, and how worthy of receiving care. The infant whose attachment initiatives have been responded to appropriately over time develops working models which say, in essence: “I can expect that people will respond to me with interest, concern and empathy. My actions are effective in communicating my needs and maintaining my attachments.”

A central component of working models is a view of the self within relationships, which contributes strongly to the child’s self-representation. The child with a history of secure attachment is likely to develop a positive sense of self, while children with insecure attachments are more likely to develop disturbances in the view of self and in the capacity to maintain self-esteem. Working models also include a view of one’s ability to regulate arousal and cope with stress. Infants who have been effectively helped with regulation of arousal through the soothing and contingent responding of their caregivers develop effective internal and social strategies for regulating affect and arousal and become more competent at coping with stress. By contrast, infants who have experienced high levels of arousal and intense affect, without the help of mutual regulation, are likely to internalize a view of the self as ineffective or out of control and to develop maladaptive coping strategies, such as affective numbing or hyper-reactivity leading to aggression and tantrums.

Once established, working models tend to become unconscious. They become filters and organizers of the child’s perceptions about relationships. They increasingly guide how the child appraises what is happening in relationships and how she behaves with others. By the third year, the working models developed through the child’s primary attachment relationships have become relatively stable, and are now applied to other relationships. The 3 year old with a history of secure attachment tends to expect that child care providers will be interested, supportive and responsive. The child with a history of insecure attachment may mistrust the intentions and emotional responsiveness of other adults. In either case, the child unconsciously attempts to organize, shape and perhaps control new relationships to make them fit her internal working models.

At the same time, assuming that parental behavior in relation to the child remains relatively constant, the child’s working models are continually being reinforced through ongoing transactions with parents. Although working models can change through changes in parenting style and experiences in new relationships, this becomes increasingly harder after they have become stabilized between ages 3-4. An obvious example is that many children who enter foster care following removal from the parents because of physical abuse behave in ways that seem intended to provoke abusive responses from foster parents. When the child projects working models in this way, the responses of others often reinforce working models, stabilizing them further. For example, if the foster parent reacts negatively (though not abusively) to the abused child’s provoking behavior, the child’s affective experience with a new caregiver feels consistent with abuse, and his working models are confirmed. However, many abused children do not continue to re-enact old relationships, but instead are gradually influenced by the responsive and empathic behavior of new caregivers. Although working models tend to be powerful and persistent, they can be changed through good care.

Longitudinal research by Alan Sroufe and his associates at University of Minnesota has found impressive links between quality of attachment in infancy and later development. Secure attachment in infancy and toddlerhood predicts social competence, good problem solving abilities, and other personality qualities associated with successful adaptation in later childhood, adolescence, and adulthood. Insecure attachment has been similarly linked to problematic behavior and social difficulties in school age children. Although other factors such as infant temperament and environmental risk factors influence outcomes, the overwhelming evidence of empirical studies makes clear that quality of attachment is a fundamental mediator of development.

Attachment Research

Attachment theory has become one of the most important constructs informing the study of human development. I do not have space to discuss the many directions attachment research has taken. (A good review of that research up to 1999 is represented in J. Cassidy & P. R. Shaver (Eds., 1999), “Handbook of Attachment,” New York: Guilford Press). Instead, I will briefly summarize research on patterns of attachment, in particular because it is so relevant to infant mental health practice.

In the 1960’s Mary Ainsworth did an observational field study of mother-infant interaction patterns of the Ganda people of Uganda. She found that two factors – maternal responsiveness and sensitivity, and infant reactions to separation – were the most important indicators of quality of attachment behavior of Ganda mothers and infants. Based on these observations, Ainsworth developed the “Strange Situation” procedure in order to assess the quality of attachment. This procedure aims to create mild but increasing stress on the attachment relationship, in order to observe the 12 to 18 month old infant’s attachment strategies and the degree of security of attachment. The most stressful episodes in the Strange Situation involve the mother’s leaving the infant with a stranger, returning briefly, and then, after the stranger leaves, leaving the baby alone very briefly. Ainsworth found that the infant’s response to the mother’s return was the most sensitive indicator of quality of attachment. Securely attached infants showed characteristic responses when reunited with the mother, and insecurely attached infants also reacted in distinctive ways.

Secure (Group B) infants reacted to the mother’s return with relief and pleasure, immediately seeking comfort from her if they were distressed, and calmed quickly in response to the mother’s soothing. Their history of responsive care gave them confidence their mother would be emotionally available to them following the stress of a brief separation.

Insecure-Avoidant (Group A) infants tended to ignore or avoid the mother at reunion and continued to play in an independent and self-reliant way. Given the normal importance of attachment for an infant, attachment theorists have described the Avoidant pattern as a defensive strategy. Ainsworth’s concurrent double-blind in-home study suggested why an avoidant defense might be needed: the Group A babies were frequently ignored and actively rejected by their mothers, who tended to reject or punish the infant for being distressed. Out of these interactions, Avoidant babies develop precocious defenses against feelings of distress. Distress is split off from consciousness, and the defense mechanism of isolation of affect emerges. Avoidant infants tend not to show upset in situations that are distressing for most infants; rather they appear somber, expressionless or self-contained. The Avoidant pattern should not be equated with non-attachment. Rather, the defensive strategy of avoidance is the baby’s way of staying close to the parent while protecting herself from overt rejection. The Avoidant pattern predicts inappropriate self-reliance and negativity and mistrust in relationships in future development.

Insecure-Ambivalent/Resistant (Group C) infants showed behavior in the Strange Situation that conveyed a strong need for attachment but a lack of confidence in its availability. They reacted with great distress to the separation, could not be soothed by their mothers, and angrily resisted comforting even though they clearly wanted it. The in-home study described the mothers of ambivalent infants as inconsistently responsive to their infants’ attachment-seeking behavior. The infants’ heightened affect and ambivalent behavior reflect their anxious uncertainty about how their parent will respond. The C pattern predicts continuing preoccupation with attachment concerns and problems functioning autonomously in later development.

Mary Main and her colleagues developed a protocol, the Adult Attachment Interview, that reliably assesses attachment styles in parents. What distinguishes “Secure” adults is their ability to speak openly and coherently about, to understand, and to integrate their early attachment experiences. “Insecure” adults (in categories that parallel the A, C, and D infant classifications) have difficulty giving coherent accounts of their own attachment experiences, rely on defensive processes that make integration of experience difficult, and tend to either dismiss the importance of attachment or to remain preoccupied with anxiety about their attachments. Independent assessments of the infants of parents studied using the Adult Attachment Interview show that adults in the Secure category have infants who are also judged secure, while Insecure adults have infants who are classified into one of the insecure categories.

The Attachment Perspective in Infant Mental Health Practice

The utility of the research findings that have validated attachment theory is that they orient us to observe interactional sequences and to look for congruency between parental working models of attachment and infant/child attachment patterns. For example, on a home visit a worker notes that a parent treats her baby roughly while changing his diaper, and seems frustrated over having to care for him. At the same time, the baby does not look at his mother, turning his head away when she comes near. These observations, which must be supported by future observations, suggest an Avoidant attachment.

Parents with working models derived from histories of secure attachment are responsive to their children, who in turn tend to develop secure attachments and positive working models. In contrast, parents who dismiss the importance of attachment are likely to dismiss their children’s needs for comforting and nurturance. When these negative attitudes carry over into caretaking transactions, the infant is likely to adopt the Avoidant pattern.

Although research contributes to our clinical understanding, it is important to distinguish between research instruments and clinical practice. The Ainsworth Strange Situation and Main’s Adult Attachment Interview reliably reveal attachment patterns when applied to individuals in a research setting. However, they are not directly transferable to practice. Research procedures require adherence to protocol, while clinical practice requires the flexibility to respond to the needs and manner of presentation of clients, and emphasizes the importance of developing a collaborative relationship with the parent. Nevertheless, knowledge of attachment patterns derived from research allows the infant clinician to observe for interactions and behavior that suggest a particular type of attachment.

Due to space considerations a bibliography is not included. Complete references are found in D. Davies text (2004). Child Development: A Practitioner’s Guide (2^nd Edition). New York: Guilford Press.