Attachment-based therapy

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Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. [1] Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy. [2] The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder.

Contents

Individual therapeutic approaches

Child–parent psychotherapy (CPP)

Child–Parent Psychotherapy (CPP) is an intervention designed to treat the relationship between children ages 0–5 and their caregivers after exposure to trauma or in high risk situations. [3] This intervention was developed in part from infant-parent psychotherapy, a psychoanalytic approach to treating disturbed infant-parent relationships based on the theory that disturbances are manifestations of unresolved conflicts in the parent's past relationships. This broader idea is represented as "ghosts in the nursery", indicating the continued presence of earlier caregiving generations [4] Infant–parent psychotherapy was expanded by Alicia Lieberman and colleagues into child–parent psychotherapy, a manualized intervention for impoverished and traumatized families with children under the age of 5. In addition to the focus on the parents early relationships the intervention also addresses current life stresses and cultural values. CPP incorporates attachment theory by considering how attachment bonds are formed between child and caregiver. CPP considers how traumatic experiences may influence attachment bonds and how caregiver's sensitivity may influence the infant's behaviors. [5] [6] ) CPP also incorporates developmental theories by considering the influences of risk factors and treatment on biological, psychological, social, and cultural development of both the child and caregiver. [7]

The "patient" is the infant–caregiver relationship. The main goal of CPP treatment is to support the parent-child relationship in order to strengthen cognitive, social, behavioral, and psychological functioning. [8] CPP is delivered in one 1–1.5-hour session per week for a year, with both the child and the caregiver/s. [8] In treatment, the child and caregiver are introduced to the formulation triangle. The triangle helps the child and caregiver to visualize how experiences influence behaviors and feelings and how CPP treatment will target those behaviors and feelings to in turn change experiences. [3] CPP treatment encourages joint play, physical contact, and communication between the child and caregiver. [3] The therapist serves to guide treatment, interpret thoughts and behaviors, and emotionally support the child and caregiver. [3]

CPP is supported by five randomized trials showing efficacy in increasing attachment security, maternal empathy and goal-corrected partnerships. The trials also showed a reduction in avoidance, resistance and anger. [3] The trials were conducted with low income groups, maltreating families, families with depressed mothers and families where children were exposed to domestic violence. [9]

Training for CPP is conducted through the Early Trauma Treatment Network, a division of the Substance Abuse and Mental Health Services Administration's National Child Traumatic Stress Network (NCTSN). [3] CPP training lasts 18 months. [3]

Attachment and Biobehavioral Catch-Up (ABC)

Attachment and Biobehavioral Catch-Up (ABC) is a parenting intervention for primary caregivers of infants or toddlers who have experienced early adversity such as abuse, neglect, poverty, and/or placement instability. It is a 10-week long intervention that consists of 10 one-hour sessions conducted on a weekly basis. Each session is led by a certified parent-coach and occurs at home.

The three goals of the intervention are to:

  1. Increase nurturing behaviors of the caregiver
  2. Enhance the caregiver's ability to follow the child's lead with delight
  3. Decrease potentially harsh or frightening behaviors of the caregiver

The ability of young children to regulate their behaviors, emotions, and physiology is strongly associated with the quality of the relationship they have with their caregiver. [10] By changing the caregiver's behavior, ABC also seeks to help young children enhance their behavioral and regulatory capabilities. Studies have shown that ABC improves child attachment quality, [11] increases caregiver sensitivity to child's behavioral signals, [12] and boosts children's executive functioning. [13] While it was originally developed by Dr. Mary Dozier at the University of Delaware for caregivers of infants ages 6–24 months (ABC-Infant), it has since been expanded to include toddlers ages 24–48 months (ABC-Toddler).

The Bakermans-Kranenburg, Van IJzendoorn and Juffer meta analysis

This was an attempt to collect and synthesise the data to try to come to "evidence-based" conclusions on the best intervention practices for attachment in infants. There were four hypotheses:

The selection criteria were very broad, intending to include as many intervention studies as possible. Sensitivity findings were based on 81 studies involving 7,636 families. Attachment security involved 29 studies and 1,503 participants. Assessment measures used were the Ainsworth sensitivity rating, Ainsworth et al. (1974), the Home Observation for Measurement of the Environment, Caldwell and Bradley (1984), the Nursing Child Assessment Teaching Scale, Barnard et al. (1998) the Erickson rating scale for maternal sensitivity and supportiveness, Egeland et al. (1990).

The conclusion was that "Interventions with an exclusively behavioural focus on maternal sensitivity appear to be most effective not only in enhancing maternal sensitivity but also in promoting children's attachment security." [14]

"Watch, wait and wonder"

This intervention involved mothers and infants referred for a community health service. Presenting problems included feeding, sleeping, behavioural regulation, maternal depression and feelings of failure in bonding or attachment. The randomly assigned control group undertook psychodynamic psychotherapy.

The primary work is between mother and therapist. It is based on the notion of the infant as initiator in infant–parent psychotherapy. For half the session the mother gets down on the floor with the infant, observes it and interacts only on the infant's initiative. The idea is that it increases the mother's sensitivity and responsiveness by fostering an observational reflective stance, whilst also being physically accessible. Also the infant has the experience of negotiating their relationship with their mother. For the second half the mother discusses her observations and experiences.

Infants in the watch, wait and wonder group were significantly more likely to shift to a secure or organised attachment classification than infants in the psychodynamic psychotherapy group although there was no differential treatment effect in maternal sensitivity. It has been pointed out however that specific caregiver responses to attachment (the precursors to secure attachments) were not measured. [15] [14]

A UK review found that Watch, Wait and Wonder was the 8th most common intervention used in the UK. It found that the evidence base to support the intervention was weak. The review also found that the most commonly used interventions had a limited evidence base and other interventions with a strong evidence base were the least commonly used. [16] [17]

"Manipulation of sensitive responsiveness"

This intervention focused on low socio-economic group mothers with irritable infants, assessed on a behavioural scale. The randomly assigned group received 3 treatment sessions, between the ages of 6 and 9 months, based on maternal responsiveness to negative and positive infant cues. Intervention was based on Ainsworth's sensitive responsiveness components, namely perceiving a signal, interpreting it correctly, selecting an appropriate response and implementing the response effectively.

It was found that these infants scored significantly higher than the control infants on sociability, self soothing and reduced crying. All maternal components improved. Further, a 'strange situation' assessment carried out at 12 months showed only 38% classified as insecure compared to 78% in the control group.

Follow ups at 18, 24 and 42 months using Ainsworth's Maternal Sensitivity Scales, the Bayley Scales of Infant Development, the Child Behaviour Checklist (Achenbach) and the Attachment Q-sort showed enduring significant effects in secure attachment classification, maternal sensitivity, fewer behaviour problems, and positive peer relationships. [18] [19]

"Modified interaction guidance"

This intervention aimed to reduce inappropriate caregiver behaviours as measured on the AMBIANCE (atypical maternal behaviour instrument for assessment and classification). Such inappropriate behaviours are thought to contribute to disorganized attachment. The play focused intervention (MIG) was compared with a behaviour modification intervention focused on feeding. A significant decrease in inappropriate maternal behaviours and disrupted communication was found in the MIG group. [20]

Feedback methods

Videofeedback intervention to promote positive parenting (VIPP)

Developed and evaluated by Juffer, Bakermans-Kranenburg and Van IJzendoorn, this collection of interventions aim to promote maternal sensitivity through the review of taped infant–parent interactions and written materials. The programme can also be expanded to include the parents internal working models (VIPP-R) and/or sensitive disciplinary practices (VIPP-SD). Findings from randomized controlled trials are mixed but overall supportive of efficacy, particularly for "highly reactive infants" and in reducing later externalising behaviours. The various versions show promise but research continues. [21]

Clinician assisted videofeedback exposure sessions (CAVES)

Developed by Daniel Schechter and colleagues. They developed an experimental paradigm informed by attachment theory called the Clinician Assisted Videofeedback Exposure Sessions to test whether traumatized mothers, who often suffered psychological sequalae from a history of abuse and violence, could "change their mind" about their young children. The technique used was to watch video-excerpts of play, separation and similarly stressful moments in the presence of a clinician who asks the mother to think about what she (and her child) might be thinking and feeling at the time of the excerpt and at the moment of videofeedback. It applies the principles of mentalization as an aide to emotional regulation with these traumatized parents. [22] [23] It also involves elements of prolonged exposure treatment, [24] the video-based treatment Interaction Guidance, [25] and psychodynamically-oriented child–parent psychotherapy. [26] Schechter and colleagues showed a significant change in the way mothers perceived their own child and their relationship together. [27]

VIG (video interaction guidance)

In video interaction guidance the client is guided to analyse and reflect on video clips of their own interactions (e.g. a mother with her infant). [28] Research results include that VIG enhances positive parenting skills, decreases/alleviates parental stress and is related to more positive development of the children. [29] [30] VIG is recommended by NICE in the UK. [31]

Public health programs

Tamar's Children

This is a scheme in which a version of the Circle of Security intervention was added to a jail diversion program for pregnant women with a history of substance abuse. Preliminary data indicates a 68% rate of secure infant–mother attachment in the first relatively small (19) sample. This is a rate of secure attachment typically found in low risk samples. [1]

Florida Infant Mental Health Pilot Program

This project tested the provision of 25 sessions of child–parent psychotherapy (see above) for mothers investigated or substantiated for child maltreatment through court-based teams. There were no further reports of maltreatment by participants during and immediately after the programme and positive changes in maternal and child behaviours were noted. The advocacy organisation Zero to Three is supporting such teams being established in other states. [32]

Foster care interventions

New Orleans Intervention/Tulane Infant Team

This is a foster care intervention devised by J.A. Larrieu and C.H Zeanah in 1998. [33] The program is designed to address the developmental and health needs of children under the age of 5 who have been maltreated and placed in foster care. It is funded by the state government of Louisiana and private funds. It is a multidisciplinary approach involving psychiatrists, psychologists, social workers, paediatricians and paraprofessionals—all with expertise in child development and developmental psychopathology.

The aim of the intervention is to support the building of an attachment relationship between the child and foster carers, even though about half of the children eventually return to their parents after about 12 to 18 months. The designers note Mary Doziers program to foster the development of relationships between children and foster carers (ABC) and her work showing the connection between foster children's symptomology and foster carers attachment status. Work is based on findings that the qualitative features of a foster parents narrative descriptions of the child and relationship with the child have been strongly associated with the foster parents behavior with the child and the child's behavior with them. [34] The aim was to develop a programme for designing foster care as an intervention.

The theoretical base is attachment theory. There is a conscious effort to build on recent, although limited, research into the incidence and causes of reactive attachment disorder and risk factors for RAD and other psychopathologies.

Soon after coming into care the children are intensively assessed, in foster care, and then receive multi modal treatments. [35] Foster carers are also formally assessed using a structured clinical interview which includes in particular the meaning of the child to the foster parent. Individualised interventions for each child are devised based on age, clinical presentation and information on the child/foster carer match. The assessment 'team' remains involved in delivering the intervention. Those running the programme maintain regular phone and visit contact and there are support groups for foster parents.

Barriers to attachment are considered to be as follows;

Interventions include supporting foster parents to learn to help the child in regulating emotions, to learn to respond effectively to the child's distress and to understand the child's signals, especially 'miscues' as the signals of such children are often confusing as a consequence of their often frightening, inconsistent and confusing past relationships. Foster carers are taught to recognize what such children actually need rather than what they may appear to signal that they need. Such children often exhibit provocative and oppositional behaviors which may normally trigger feelings of rejection in caregivers. Withdrawn children may be overlooked and seemingly independent, indiscriminate children may be considered to be managing much better than they are. Foster carers are regularly contacted and visited to assess their needs and progress.

As of 2005, 250 children had participated in the programme. Outcome data published in 2001 revealed a 68% reduction in maltreatment recidivism for the same child returning to its parent(s)and a 75% reduction in recidivism for a subsequent child of the same mother. The authors claim the programme not only assists the building of new attachments to foster parents but also has the potential impact a families development long after a returned child is no longer in care. [36]

Differentiation from attachment therapy

It is critical to differentiate therapies based on attachment theory from the "unfortunately named" attachment therapy. [37] (However, the use of the terms "attachment therapy" and "attachment-based therapy" is not consistent in literature and on the Internet). Attachment therapy, also known as 'holding therapy', is a group of unvalidated therapies characterized by forced restraint of children in order to make them relive attachment-related anxieties; a practice considered incompatible with attachment theory and its emphasis on 'secure base'. [2] The conceptual focus of these treatments is the child's individual internal pathology and past caregivers rather than current parent-child relationships or current environment. [38] This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with which it is considered incompatible. [2] [39] In 2006, the American Professional Society on the Abuse of Children (APSAC) Task Force reported on the subjects of attachment therapy, reactive attachment disorder, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorders. [38] The Taskforce was largely critical of attachment therapy's theoretical base, practices, claims to an evidence base, non-specific symptoms lists published on the internet, claims that traditional treatments do not work and dire predictions for the future of children who do not receive attachment therapy. The controversy also extends to the theories, diagnoses, diagnostic practices, beliefs, and social group norms and patient recruitment and advertising practices. [38]

See also

Related Research Articles

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from unavailability of normal socializing care and attention from primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers between three months and three years of age, frequent change or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts resulting in a lack of basic trust. A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children, although these issues do occasionally persist into adulthood. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited attachment disorder".

<span class="mw-page-title-main">Attachment theory</span> Psychological ethological theory about human relationships

Attachment theory is a psychological, evolutionary and ethological theory concerning relationships between humans. The most important tenet is that young children need to develop a relationship with at least one primary caregiver for normal social and emotional development. The theory was formulated by psychiatrist and psychoanalyst John Bowlby.

Dyadic developmental psychotherapy is a psychotherapeutic treatment method for families that have children with symptoms of emotional disorders, including complex trauma and disorders of attachment. It was originally developed by Arthur Becker-Weidman and Daniel Hughes as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers. Hughes cites attachment theory and particularly the work of John Bowlby as theoretical motivations for dyadic developmental psychotherapy.

<span class="mw-page-title-main">Attachment in children</span> Biological instinct

Attachment in children is "a biological instinct in which proximity to an attachment figure is sought when the child senses or perceives threat or discomfort. Attachment behaviour anticipates a response by the attachment figure which will remove threat or discomfort". Attachment also describes the function of availability, which is the degree to which the authoritative figure is responsive to the child's needs and shares communication with them. Childhood attachment can define characteristics that will shape the child's sense of self, their forms of emotion-regulation, and how they carry out relationships with others. Attachment is found in all mammals to some degree, especially primates.

Attachment measures refer to the various procedures used to assess the attachment system in children and adults. Researchers have developed various ways of assessing self-protective strategies and patterns of attachment. Some methods work across the several models of attachment and some are model-specific.

Attachment therapy is a pseudoscientific child mental health intervention intended to treat attachment disorders. It is found primarily in the United States, and much of it is centered in about a dozen clinics in Evergreen, Colorado, where Foster Cline, one of the founders, established his clinic in the 1970s.

Child psychotherapy, or mental health interventions for children refers to the psychological treatment of various mental disorders diagnosed in children and adolescents. The therapeutic techniques developed for younger age ranges specialize in prioritizing the relationship between the child and the therapist. The goal of maintaining positive therapist-client relationships is typically achieved using therapeutic conversations and can take place with the client alone, or through engagement with family members.

In psychology, mentalization is the ability to understand the mental state – of oneself or others – that underlies overt behaviour. Mentalization can be seen as a form of imaginative mental activity that lets us perceive and interpret human behaviour in terms of intentional mental states. It is sometimes described as "understanding misunderstanding." Another term that David Wallin has used for mentalization is "Thinking about thinking". Mentalization can occur either automatically or consciously. Mentalization ability, or mentalizing, is weakened by intense emotion.

Parent–child interaction therapy (PCIT) is an intervention developed by Sheila Eyberg (1988) to treat children between ages 2 and 7 with disruptive behavior problems. PCIT is an evidence-based treatment (EBT) for young children with behavioral and emotional disorders that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns.

<span class="mw-page-title-main">Maternal deprivation</span> Work on the effects of separating infants/young children from their mother

Maternal deprivation is a scientific term summarising the early work of psychiatrist and psychoanalyst John Bowlby on the effects of separating infants and young children from their mother. Although the effect of loss of the mother on the developing child had been considered earlier by Freud and other theorists, Bowlby's work on delinquent and affectionless children and the effects of hospital and institutional care led to his being commissioned to write the World Health Organization's report on the mental health of homeless children in post-war Europe whilst he was head of the Department for Children and Parents at the Tavistock Clinic in London after World War II. The result was the monograph Maternal Care and Mental Health published in 1951, which sets out the maternal deprivation hypothesis.

Charles H. Zeanah Jr. is a child and adolescent psychiatrist who is a member of the council (Board) of the American Academy of Child and Adolescent Psychiatry (AACAP).

Mary Main was an American psychologist notable for her work in the field of attachment. A Professor at the University of California Berkeley, Main is particularly known for her introduction of the 'disorganized' infant attachment classification and for development of the Adult Attachment Interview and coding system for assessing states of mind regarding attachment. This work has been described as 'revolutionary' and Main has been described as having 'unprecedented resonance and influence' in the field of psychology.

<span class="mw-page-title-main">Daniel Schechter</span> American neuroscientist

Daniel S. Schechter is an American and Swiss psychiatrist known for his clinical work and research on intergenerational transmission or "communication" of violent trauma and related psychopathology involving parents and very young children. His published work in this area following the terrorist attacks on the World Trade Center in New York of September 11, 2001 led to a co-edited book entitled "September 11: Trauma and Human Bonds" (2003) and additional original articles with clinical psychologist Susan Coates that were translated into multiple languages and remain among the first accounts of 9/11 related loss and trauma described by mental health professionals who also experienced the attacks and their aftermath Schechter observed that separation anxiety among infants and young children who had either lost or feared loss of their caregivers triggered posttraumatic stress symptoms in the surviving caregivers. These observations validated his prior work on the adverse impact of family violence on the early parent-child relationship, formative social-emotional development and related attachment disturbances involving mutual dysregulation of emotion and arousal. This body of work on trauma and attachment has been cited by prominent authors in the attachment theory, psychological trauma, developmental psychobiology and neuroscience literatures

Patricia McKinsey Crittenden is an American psychologist known for her work in the development of attachment theory and science, her work in the field of developmental psychopathology, and for creation of the Dynamic-Maturational Model of Attachment and Adaptation (DMM).

<span class="mw-page-title-main">Maternal sensitivity</span>

Maternal sensitivity is a mother's ability to perceive and infer the meaning behind her infant's behavioural signals, and to respond to them promptly and appropriately. Maternal sensitivity affects child development at all stages through life, from infancy, all the way to adulthood. In general, more sensitive mothers have healthier, more socially and cognitively developed children than those who are not as sensitive. Also, maternal sensitivity has been found to affect the person psychologically even as an adult. Adults who experienced high maternal sensitivity during their childhood were found to be more secure than those who experienced less sensitive mothers. Once the adult becomes a parent themselves, their own understanding of maternal sensitivity will affect their own children's development. Some research suggests that adult mothers display more maternal sensitivity than adolescent mothers who may in turn have children with a lower IQ and reading level than children of adult mothers.

Video feedback interventions are used in health and social care situations. Typically a "guider" helps a client to enhance communication within relationships. The client is guided to analyse and reflect on video clips of their own interactions. Applications include a caregiver and infant, and other education and care home interactions. Video feedback interventions have also been used where concerns have been expressed over possible parental neglect in cases where the focus child is aged 2–12, and where the child is not the subject of a child protection plan.

Disinhibited Social Engagement Disorder (DSED), or Disinhibited Attachment Disorder, is an attachment disorder in which a child has little to no fear of unfamiliar adults and may actively approach them. It can significantly impair young children's abilities to relate with adults and peers, according to the Diagnostic and Statistical Manual of Mental Disorders. As well as put them in dangerous and potentially unsafe conditions. Common examples of this include sitting on a person's lap of which they do not know or leaving with a stranger.

Psychodynamic Therapy with Infants and Parents aims to relieve emotional disturbances within the parent(s), the baby, and/or their interaction, for example, postnatal depression and anxiety, infant distress with breastfeeding and sleep, and attachment disorders. It rests on attachment theory and psychoanalysis. Sigmund Freud suggested that a modification of his method could be applied to children, and child analysis was introduced in the 1920s by [Anna Freud].., [Melanie Klein], and Hermine Hug von Hellmuth. Klein speculated on infantile experiences to understand her patients' disorders but she did not practice PTIP. Donald Winnicott, a pediatrician and analyst, focused on the mother-baby interplay in his theorizing and his brief parent-child consultations, but he did not work with PTIP.

The dynamic-maturational model of attachment and adaptation (DMM) is a biopsychosocial model describing the effect attachment relationships can have on human development and functioning. It is especially focused on the effects of relationships between children and parents and between reproductive couples. It developed initially from attachment theory as developed by John Bowlby and Mary Ainsworth, and incorporated many other theories into a comprehensive model of adaptation to life's many dangers. The DMM was initially created by developmental psychologist Patricia McKinsey Crittenden and her colleagues including David DiLalla, Angelika Claussen, Andrea Landini, Steve Farnfield, and Susan Spieker.

References

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  26. ↑ Lieberman, A.F.; Van Horn, P.; Ippen, C.G. (2005). "Towards evidence-based treatment: Child-parent psychotherapy with preschoolers exposed to marital violence". Journal of the American Academy of Child and Adolescent Psychiatry. 44 (12): 1241–1248. doi:10.1097/01.chi.0000181047.59702.58. PMID   16292115.
  27. ↑ Schechter, DS; Myers, MM; Brunelli, SA; Coates, SW; Zeanah, CH; Davies, M; Grienenberger, JF; Marshall, RD; McCaw, JE; Trabka, KA; Liebowitz, MR (2006). "Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributions". Infant Mental Health Journal. 27 (5): 429–448. doi:10.1002/imhj.20101. PMC   2078524 . PMID   18007960.
  28. ↑ "Practice video interaction guidance". Archived from the original on March 17, 2014. Retrieved March 22, 2014.
  29. ↑ "Research on video interaction guidance". Archived from the original on March 17, 2014. Retrieved March 22, 2014.
  30. ↑ "Patterns of Attachment in Infancy - Dynamic Maturational Model Family Relations Institute".
  31. ↑ "Social and emotional wellbeing: Early years Recommendations PH40". Archived from the original on April 5, 2013. Retrieved December 14, 2012.
  32. ↑ Berlin LJ, Zeanah CH, Lieberman AF (2008). "Prevention and Intervention Programs for Supporting Early Attachment Security". In Cassidy J, Shaver PR (eds.). Handbook of Attachment, Second Edition: Theory, Research, and Clinical Applications. Handbook of Attachment: Theory, Research and Clinical Applications. New York, London: Guilford Press. pp. 755–756. ISBN   978-1-59385-874-2.
  33. ↑ Larrieu, J. A.; Zeanah, C.H. (1998). "Intensive intervention for maltreated infants and toddlers in foster care". Child and Adolescent Psychiatric Clinics of North America. 7 (2): 357–371. doi:10.1016/S1056-4993(18)30246-3. PMID   9894069.
  34. ↑ Zeanah, C.H., Aoki, Y., Heller, S.S., & Larrieu, J.A. (1999) Relationship specificity in maltreated toddlers and their birth and foster parents. Paper presented at the annual meeting of the Society for Research in Child Development, Albuquerque, NM.
  35. ↑ Larrieu, J.A., & Zeanah, C.H. (2004). Treating infant–parent relationships in the context of maltreatment: An integrated, systems approach. In A.Saner, S. McDonagh, & K. Roesenblaum (Eds.) Treating parent-infant relationship problems ( pp. 243–264) New York: Guilford Press
  36. ↑ Zeanah, C., H. and Smyke, A., T. "Building Attachment Relationships Following Maltreatment and Severe Deprivation" Interventions to Enhance Attachment, Berlin, L., J., Ziv, Y., Amaya-Jackson, L. and Greenberg, M., T. pps 195–216 The Guilford Press, 2005
  37. ↑ Dozier M, Rutter M (2008). "Challenges to the Development of Attachment Relationships Faced by Young Children in Foster and Adoptive Care". In Cassidy J, Shaver PR (eds.). Handbook of Attachment: Theory, Research and Clinical Applications (2nd ed.). New York: London: Guilford Press. ISBN   978-1-60623-028-2.
  38. 1 2 3 Chaffin M, Hanson R, Saunders BE, et al. (2006). "Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems". Child Maltreat. 11 (1): 76–89. doi:10.1177/1077559505283699. PMID   16382093. S2CID   11443880.
  39. ↑ O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev. 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID   12944216. S2CID   21547653.
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