588650 research-article2015
CCP0010.1177/1359104515588650Clinical Child Psychology and PsychiatryEditorial
Editorial
Understanding children: Assessing school-aged children’s self-protective attachment strategies
Clinical Child Psychology and Psychiatry 2015, Vol. 20(3) 341–347 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359104515588650 ccp.sagepub.com
Patricia McKinsey Crittenden Family Relations Institute, Miami, FL, USA
School-aged children who present for psychotherapy are often very perplexing. Their symptoms are clear and concerning, but the reasons for the symptoms are obscure. The parents describe the progress of the symptoms, but usually have little understanding of the process that resulted in problems. The children are even less informative and, when the symptoms are quite severe, children’s communication may become almost inscrutable. Nevertheless, astute clinicians have often felt the children had a coherent story to tell if we just knew how to listen. The papers presented in this Special Section of Clinical Child Psychology and Psychiatry (CCPP) describe the process and outcomes of a series of studies exploring the reliability, validity, and utility of the School-aged Assessment of Attachment (SAA). The SAA uses children’s narratives about threats that school-aged children fear (and sometimes experience) and the self-protective attachment strategies that they organize to protect and comfort themselves. Clinicians need an assessment that discriminates within the group of risk children and does so by adding to what is already known (as opposed to corroborating the known risk/non-risk status of the child). Furthermore, the new information must have implications for more precise treatment than would have been offered without the assessment. This is the issue of utility. Researchers need an assessment with construct validity (as opposed to the face validity of calling it “attachment”) and reliability among coders. Children need an assessment that engages them in ways that are suitable for their age and development, and that addresses their concerns. However, the two best validated assessments of attachment (the Ainsworth Strange Situation and George/Main Adult Attachment Interview) are inappropriate for school-aged children. Short separations do not elicit attachment strategies in school-aged children and Adult Attachment Interview (AAI)-style questions, aimed at integrating early and current events with their implications for the self in the present, are beyond children’s maturational capacity. Although a number of approaches have been offered for the school years, none has yet achieved wide acceptance, nor has any been validated sufficiently to justify such acceptance.
Constructing a developmentally attuned and clinically informative assessment Attachment and school-aged children’s development In infancy, attachment is person-specific, that is, the attachment between an infant and a specific parent. By adulthood, attachment can be integrated to a generalized pattern that adults use in many
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relationships (albeit some troubled adults continue to have unintegrated strategies). The challenge in the school years is to reflect the transition from relationship-specific attachment to generalized psychological strategies. The SAA was developed from a series of assessments, beginning with the Separation Anxiety Test (Hansburg, 1972), its adaptation for children (Klagsbrun & Bowlby, 1976), and its adaptation to different dangers by Resnick (1993) and Slough, Goyette, and Greenberg (1988). These tools used picture cards to elicit attachment strategies. The threats chosen for the SAA were going out alone, being rejected by peers, moving house, bullying, the father leaving home, the child running away, and the mother going to hospital. In the studies presented here, foster children often reacted strongly to the moving house card, normative children from troubled homes reacted to the father going away card (because it elicited concerns about parental conflict), and children from homes with violence often responded strongly to the mother to hospital card. Almost all very anxious children reacted to the going out alone card—which was meant to elicit very little, if any, distress. Instead of Hansburg’s set of closed questions or Resnick’s opened-ended requests for stories, the SAA called for stories, followed by a defined set of theoretically important questions (Crittenden & Landini, 1999). The follow-up questions addressed the temporal order of the children’s stories, that is, what happened first? Next? How did it end? These were the “cognitive” probes. Other questions asked how the child felt, the “affect” probes. The child was asked how the mother and father felt and what they were thinking; these were theory of mind questions. Finally, the child was asked what he or she would do now if this happened again. This question probed concrete integrative capacity. Because children differ in how they address troubling topics, each card was used to elicit two stories, a fantasy story about the boy or girl pictured on the card and a recalled, personal episode about the same sort of event. This capitalized on school-aged children’s ability to differentiate self from other (as 4- to 5-year-old children cannot). Fantasy stories allowed children explore threatening topics and solutions from a distance, without directly tying their thoughts to their own lives. We observed that well-developing children provided both fantasy and recalled episodes, whereas some distressed children provided only one or the other. In these cases, either the child did not dare to speculate beyond a factual (cognitive) presentation or the child could only speak in an “as if” state. In most cases, children made “slips” in the fantasy stories that indicated that they were basing the fantasy child on themselves, for example, slips from third person pronouns to the first person or the application of personal information to the imagined child.
Choosing a classificatory system Many assessments of attachment use a gradient from secure to insecure, secure or insecure categories, ABC categories, or ABC + D categories. We used the Dynamic-Maturational Model (DMM) of Attachment and Adaptation self-protective strategies (Crittenden, 2015) which, we hoped, would both fit school-aged children’s protective organization and also permit differentiation of degree of risk and type of risk. The DMM offers several Type A(1-4), B(1-5), and C(1-6) strategies, plus an assortment of unresolved traumas and losses (e.g. preoccupied, dismissed, vicarious, displaced, depressed, etc.), and four “modifying” conditions that affected the strategy itself (depression, disorientation, intrusions of forbidden negative affect, and expressed somatic symptoms). Finally, the DMM included the concept of reorganization, thus permitting a process of change to be identified. This construct is especially important for psychotherapists. A central difference between the DMM classificatory system and all other systems is the emphasis on adaptation to context as opposed to security. This is particularly important in clinical applications where security is rare and adaptation is more important.
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Using discourse analysis with school-aged children Because school-aged children are still learning to use language, full reliance on discourse analysis might restrict what we could understand from what children told us. Stories, on the other hand, could be entirely made up and not accurately reflect children’s experience or their strategies for coping with problems. We chose to use both a simplified DMM-AAI discourse analysis (Crittenden & Landini, 2011) and interpretation of the plots and themes of the 14 stories derived from the seven cards. As with all Ainsworth-based assessments, we looked for repeated patterns (as opposed to ratings or other quantitative measures) of discourse functions and story themes and elements. The discourse functions included idealization, preoccupation, denial, and so forth. Story themes included helping someone else, getting into fights, and disastrous endings. Story elements included such things as calling the police to resolve problems. In each case, the markers had to be repeated within and across cards before meaning was attributed. Unresolved traumas and losses were especially hard to identify. These are not apparent in the Strange Situation, whereas in the AAI, they refer to specific historical events. The SAA fell between these assessments with some SAAs containing discourse markers indicative of psychological trauma that could not be assigned specific events. In addition, many of these events were only partially understood by the children who, therefore, could not relate them accurately. This was particularly true for parental conflict, parental infidelity, and parents’ response to losses, especially of other children. Modifiers were identified from specified discourse markers, aspects of story plots or themes, and non-verbal actions. Non-verbal action was noted either by the interviewer (e.g. “You looked really sad when you said that. Did you feel sad?”) or added by the transcriber (intense coughing, scraping of the microphone so speech couldn’t be heard).
Refining and fine-tuning the emerging SAA Over a period of several years, clinicians met in small groups to code and discuss SAA transcriptions. Slowly, in a recursive process that was informed by clinicians, the discourse analysis was refined. The goals were to devise an assessment procedure that appealed to children and a classificatory method and system that differentiated between well-functioning and troubled children and, in addition, revealed important clinical differences among troubled children. More than 50 cases were studied in residential clinical seminars. Other cases were examined by email. A guide was written that addressed both discourse and thematic content in six memory systems (procedural, imaged, semantic, connotative language, episodic, and concrete reflective functioning), plus the somatic non-verbal notes. These were used to define a strategy with, possibly, unresolved traumas or losses and modifiers.
Validating the SAA A plan to validate the SAA Once the goal of engaging children was met and clinically relevant information was identified on a case-by-case basis, it was time to validate the SAA. An optimistic 5-year plan to assess coder reliability, classification validity, and clinical utility was drawn up. Studies were planned to assess (a) whether the SAA discriminated risk from non-risk children (in terms of child diagnosis, clinical measures, and parent functioning), (b) whether there was continuity in children’s strategies from late preschool to the school years, and (c) whether the SAA predicted differences in future functioning.
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Discriminating risk from non-risk Kasia Kozlowska gathered the first set of SAA data on an Australian set of normative children and children referred to child psychiatry at a children’s hospital. The SAAs of these children demonstrated both discriminant validity and also a relation between child and parent psychiatric diagnoses. Uniformly, diagnosed children had parents with one or more psychiatric diagnoses (Crittenden, Kozlowska, & Landini, 2010). Two small, possibly idiosyncratic, results were also found: (a) two normative children had SAAs with “clinical” classifications—in one case, the father had recently been attacked at home, and in the other, the parents divorced within the year and (b) two clinical children had SAAs that classified as “B”—both were approaching discharge after a successful course of treatment. If these findings hold in larger samples, they suggest what the SAA can add to what professionals know. The finding regarding risk versus non-risk was replicated by Kwako, Noll, Putnam, and Trickett (2010) on an American sample; Crittenden, Robson, and Tooby (this issue) on a British sample; and Nuccini, Paterlini, Gargano, and Landini (this issue) on an Italian sample. Strikingly, the greatest differences were not in protective attachment strategy, but rather in depression and unresolved trauma. This suggests that non-B strategies can be adaptive when not disrupted by modifiers or traumas.
Stability of strategy One way to feel confident about the attachment strategy identified by a new assessment is to compare it to the attachment strategy derived from a well-validated assessment. Relying on the validity of the Preschool Assessment of Attachment (PAA, see Farnfield, Hautamäki, Nørbech, & Sahhar, 2010), a sample of 5.5-year-old children was gathered. They and their mothers participated in the Strange Situation for preschool-aged children (Crittenden, 1992), and then 6 months later, the SAA was given to the children and the AAI to the mothers. Concordance between PAA and SAA classification was high (Crittenden et al., this issue). It was notable, however, that the SAA classifications contained detail about psychological trauma and depression that could not be derived from the PAA. As expected, this occurred primarily in clinical cases, but again, some normative children appeared to be troubled. Epidemiologically, this would be expected in about 20–30% of cases (Dilling, Weyerer, & Castell, 1984; Hagnell, Öjesjö, Otterbeck, & Rorsman, 1994; Kessler, 1994; Roberts, Attkisson, & Rosenblatt, 1998; Rutter & Rutter, 1993). Shari Kidwell and her colleagues replicated and extended the PAA-to-SAA relation from 4 to 11 years (Kidwell et al., this issue).
Construct validity The central DMM construct that underlies anxious attachment is that protective attachment strategies are needed when individuals are exposed to danger that they cannot manage by themselves (Crittenden, 1999). Several of the SAA studies measured children’s exposure to danger; in all of these studies, greater endangerment was associated with more extreme self-protective attachment strategies. Of course, the relation was not an equivalence because information processing connected exposure to danger with self-protective strategy. Thus, when the danger was in a child’s zone of proximal development, children protected themselves and did not experience trauma. Similarly, when children and parents had completed a successful course of psychotherapy, psychological trauma was no longer observed.
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Kozlowska’s Australian sample, Robson and Tooby’s UK sample, and the American sample of Kwako and her colleagues all supported the relation of exposure to danger with extreme and sometimes ineffective self-protection and all had exceptions that were comprehensible when examined individually.
Clinical utility Applying the results of an assessment in real lives, as opposed to grouped and anonymous research data, requires strong evidence of discriminant validity, differentiable subpatterns within the clinical risk group, and high coder reliability (sustainable on a case-by-case basis). Kozlowska and her colleagues have explored the functioning of children with conversion disorders using the SAA in a series of papers (Kozlowska, Scher, & Williams, 2011; Kozlowska & Williams, 2009). They found that conversion disorders were heterogeneous with three types (A, C, and A/C), reflecting different neurobiological processes for coping with stress and requiring different forms of treatment. Nuccini and her colleagues explored the relation of very low birth weight to children’s attachment strategies (Nuccini et al., this issue). They found that low birth weight children used extreme self-protective strategies, particularly feigned helplessness. There was no difference in rates of psychological trauma, but prematurely born children had traumas about illness, whereas full-term children had traumas about family problems. Two case studies presented the use of the SAA to understand attention deficit hyperactivity disorder (ADHD) (Crittenden & Kulbotten, 2007) and fabricated illness (Kozlowska, Foley, & Savage, 2012). In both cases, parents’ concerns were central to children's problems. In the ADHD case, it was parental conflict around infidelity; in the facticious illness case, it was parents’ unresolved fear of loss.
Limitations These nine studies bode well for the validity, reliability, and utility of the SAA, but they also highlight limitations and gaps. Coder reliability was achieved in all studies, but most people who were trained did not become reliable. This suggests that assessing attachment requires specific expertise, possibly in both individual assessments and also the theory of attachment underlying the assessment. Furthermore, the events that elicited children’s strategies were not clear, nor was parental input. A detailed family history and information about parental attachment were needed to clarify the meaning of children’s SAAs. Other important topics have not yet been addressed. What about siblings? We will offer data in Part 2 of this Special Section on siblings. Is there anything the children can’t say in words? We will explore the relation of children’s family drawings to their SAAs, expecting that images will convey information that words cannot. What about the parents? We will offer data comparing mothers’ AAIs to their children’s SAAs. And specific disorders? Slowly, in the coming years, we hope to explore several important disorders in formal and case studies. We hope to identify a set of underlying intra- and interpersonal processes, as opposed to symptoms, that could be revealed through assessment and addressed through treatment.
Understanding children I began by saying it was difficult to understand distressed children. These studies support that statement: children’s communication is filled with their misunderstandings, lack of information, and need to protect themselves and their parents from what they know (or fear that they know). Nevertheless, children try, in their own way, to explain how they understand their lives. The
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combination of discourse and plot/theme analysis across seven threats, with fantasy and recalled episodes for each, can reveal the complex inner worlds of school-aged children, particularly those who feel most threatened. If there is a bottom line to an incomplete program of research, it is that children with behavioral, psychiatric, and unexplained somatic symptoms feel threatened. Decoding their narratives, combined with similarly decoded information from their parents’ AAIs and details of family history, can reveal processes that make sense for everyone: the parents who care so much for their distressed children, the children themselves, and the professionals who seek to relieve families’ suffering. If the SAA contributes to understanding children and points to the need for similar understanding of their parents, it will offer much-needed hope to both families and professionals. References Crittenden, P. M. (1992). Quality of attachment in the preschool years. Development and Psychopathology, 4, 209–241. Crittenden, P. M. (1999). Danger and development: The organization of self-protective strategies. In J. I. Vondra, & D. Barnett (Eds.), Monographs of the Society for Research on Child Development: Series No. 258. A typical attachment in infancy and early childhood among children at developmental risk (Vol. 64, pp. 145–171). Malden, MA: Wiley-Blackwell. Crittenden, P. M. (2015). Raising parents: Attachment, representation, and treatment (2nd ed.). London, England: Routledge. Crittenden, P. M., Kozlowska, K., & Landini, A. (2010). Assessing attachment in school-age children. Clinical Child Psychology and Psychiatry, 14, 185–208. Crittenden, P. M., & Kulbotten, G. R. (2007). Familial contributions to ADHD: An attachment perspective. Tidsskrift for Norsk Psykologforening, 10, 1220–1229. Crittenden, P. M., & Landini, A. (1999). Administering the school-age assessment of attachment. Unpublished manuscript. Crittenden, P. M., & Landini, A. (2011). Assessing adult attachment: A dynamic-maturational approach to discourse analysis. New York, NY: W. W. Norton. Crittenden, P. M., Robson, K., & Tooby, A. (2015, this issue). Validation of the School-age Assessment of Attachment in a short-term longitudinal study. Clinical Child Psychology and Psychiatry, 20(3), 348–365. Dilling, W., Weyerer, S., & Castell, R. (1984). Psychische Erkrankungen in der Bevölkerung. Stuttgart, Germany: Enke. Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2015, this issue). Dynamic-maturational model methods for assessing attachment. Clinical Child Psychology and Psychiatry, 15, 313–328. Hagnell, O., Öjesjö, L., Otterbeck, L., & Rorsman, B. (1994). Prevalence of mental disorders, personality traits and mental complaints in the Lundby Study. Scandinavian Journal of Social Medicine, Supplementum, 50, 1–77. Hansburg, H. G. (1972). Adolescent separation anxiety: A method for the study of adolescent separation problems. Springfield, IL: C. C. Thomas. Kessler, R. C. (1994). The national comorbidity survey of the United States. International Review of Psychiatry, 6, 365–376. Kidwell, S. L., Sizemore, K. M., Qu, J., Fugate, K. M., Deaton, M. S., & Blevins, M. D. (2015, this issue). Validity of the School-age Assessment of Attachment for moderate-risk, rural early adolescents. Clinical Child Psychology and Psychiatry, 20(3), 366–380. Klagsbrun, M., & Bowlby, J. (1976). Responses to separation from parents: A clinical test for young children. British Journal of Projective Psychiatry, 21, 7–27. Kozlowska, K., Foley, S., & Savage, B. (2012). Fabricated illness: Working within the family system to find a pathway to health. Family Process, 51, 570–587. doi:10.1111/famp.12000
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Kozlowska, K., Scher, S., & Williams, L. M. (2011). Patterns of emotional-cognitive function in pediatric conversion patients: Implications for the conceptualization of conversion disorders. Psychosomatic Medicine, 73, 775–788. Kozlowska, K., & Williams, L. M. (2009). Self-protective organization in children with conversion and somatoform disorders. Journal of Psychosomatic Research, 67, 223–233. Kwako, L. E., Noll, J. G., Putnam, F. W., & Trickett, P. K. (2010).Childhood sexual abuse and attachment: An intergenerational perspective. Clinical Child Psychology and Psychiatry, 15, 407–422. Nuccini, F., Paterlini, M., Gargano, G., & Landini, A. (2015, this issue). The attachment of prematurely born children at school age: A pilot study. Clinical Child Psychology and Psychiatry, 20(3), 381–394. Resnick, G. (1993). Measuring attachment in early adolescence: A manual for the administration, coding and interpretation of the Separation Anxiety Test for 11 to 14 year olds. Unpublished manuscript, Westat, Rockville, MD. Roberts, R. E., Attkisson, C. C., & Rosenblatt, A. (1998). Prevalence of psychopathology among children and adolescents [Special article]. American Journal of Psychiatry, 155, 715–725. Rutter, M., & Rutter, M. (1993). Developing minds: Challenge and continuity across the lifespan. New York, NY: Basic Books. Slough, N. M., Goyette, M., & Greenberg, M. T. (1988). Scoring indices for the Seattle version of the Separation Anxiety Test. Unpublished manuscript, University of Washington, Seattle.
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CCP0010.1177/1359104515588650Clinical Child Psychology and PsychiatryEditorial
Editorial
Understanding children: Assessing school-aged children’s self-protective attachment strategies
Clinical Child Psychology and Psychiatry 2015, Vol. 20(3) 341–347 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1359104515588650 ccp.sagepub.com
Patricia McKinsey Crittenden Family Relations Institute, Miami, FL, USA
School-aged children who present for psychotherapy are often very perplexing. Their symptoms are clear and concerning, but the reasons for the symptoms are obscure. The parents describe the progress of the symptoms, but usually have little understanding of the process that resulted in problems. The children are even less informative and, when the symptoms are quite severe, children’s communication may become almost inscrutable. Nevertheless, astute clinicians have often felt the children had a coherent story to tell if we just knew how to listen. The papers presented in this Special Section of Clinical Child Psychology and Psychiatry (CCPP) describe the process and outcomes of a series of studies exploring the reliability, validity, and utility of the School-aged Assessment of Attachment (SAA). The SAA uses children’s narratives about threats that school-aged children fear (and sometimes experience) and the self-protective attachment strategies that they organize to protect and comfort themselves. Clinicians need an assessment that discriminates within the group of risk children and does so by adding to what is already known (as opposed to corroborating the known risk/non-risk status of the child). Furthermore, the new information must have implications for more precise treatment than would have been offered without the assessment. This is the issue of utility. Researchers need an assessment with construct validity (as opposed to the face validity of calling it “attachment”) and reliability among coders. Children need an assessment that engages them in ways that are suitable for their age and development, and that addresses their concerns. However, the two best validated assessments of attachment (the Ainsworth Strange Situation and George/Main Adult Attachment Interview) are inappropriate for school-aged children. Short separations do not elicit attachment strategies in school-aged children and Adult Attachment Interview (AAI)-style questions, aimed at integrating early and current events with their implications for the self in the present, are beyond children’s maturational capacity. Although a number of approaches have been offered for the school years, none has yet achieved wide acceptance, nor has any been validated sufficiently to justify such acceptance.
Constructing a developmentally attuned and clinically informative assessment Attachment and school-aged children’s development In infancy, attachment is person-specific, that is, the attachment between an infant and a specific parent. By adulthood, attachment can be integrated to a generalized pattern that adults use in many
Downloaded from ccp.sagepub.com by guest on November 15, 2015
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relationships (albeit some troubled adults continue to have unintegrated strategies). The challenge in the school years is to reflect the transition from relationship-specific attachment to generalized psychological strategies. The SAA was developed from a series of assessments, beginning with the Separation Anxiety Test (Hansburg, 1972), its adaptation for children (Klagsbrun & Bowlby, 1976), and its adaptation to different dangers by Resnick (1993) and Slough, Goyette, and Greenberg (1988). These tools used picture cards to elicit attachment strategies. The threats chosen for the SAA were going out alone, being rejected by peers, moving house, bullying, the father leaving home, the child running away, and the mother going to hospital. In the studies presented here, foster children often reacted strongly to the moving house card, normative children from troubled homes reacted to the father going away card (because it elicited concerns about parental conflict), and children from homes with violence often responded strongly to the mother to hospital card. Almost all very anxious children reacted to the going out alone card—which was meant to elicit very little, if any, distress. Instead of Hansburg’s set of closed questions or Resnick’s opened-ended requests for stories, the SAA called for stories, followed by a defined set of theoretically important questions (Crittenden & Landini, 1999). The follow-up questions addressed the temporal order of the children’s stories, that is, what happened first? Next? How did it end? These were the “cognitive” probes. Other questions asked how the child felt, the “affect” probes. The child was asked how the mother and father felt and what they were thinking; these were theory of mind questions. Finally, the child was asked what he or she would do now if this happened again. This question probed concrete integrative capacity. Because children differ in how they address troubling topics, each card was used to elicit two stories, a fantasy story about the boy or girl pictured on the card and a recalled, personal episode about the same sort of event. This capitalized on school-aged children’s ability to differentiate self from other (as 4- to 5-year-old children cannot). Fantasy stories allowed children explore threatening topics and solutions from a distance, without directly tying their thoughts to their own lives. We observed that well-developing children provided both fantasy and recalled episodes, whereas some distressed children provided only one or the other. In these cases, either the child did not dare to speculate beyond a factual (cognitive) presentation or the child could only speak in an “as if” state. In most cases, children made “slips” in the fantasy stories that indicated that they were basing the fantasy child on themselves, for example, slips from third person pronouns to the first person or the application of personal information to the imagined child.
Choosing a classificatory system Many assessments of attachment use a gradient from secure to insecure, secure or insecure categories, ABC categories, or ABC + D categories. We used the Dynamic-Maturational Model (DMM) of Attachment and Adaptation self-protective strategies (Crittenden, 2015) which, we hoped, would both fit school-aged children’s protective organization and also permit differentiation of degree of risk and type of risk. The DMM offers several Type A(1-4), B(1-5), and C(1-6) strategies, plus an assortment of unresolved traumas and losses (e.g. preoccupied, dismissed, vicarious, displaced, depressed, etc.), and four “modifying” conditions that affected the strategy itself (depression, disorientation, intrusions of forbidden negative affect, and expressed somatic symptoms). Finally, the DMM included the concept of reorganization, thus permitting a process of change to be identified. This construct is especially important for psychotherapists. A central difference between the DMM classificatory system and all other systems is the emphasis on adaptation to context as opposed to security. This is particularly important in clinical applications where security is rare and adaptation is more important.
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Using discourse analysis with school-aged children Because school-aged children are still learning to use language, full reliance on discourse analysis might restrict what we could understand from what children told us. Stories, on the other hand, could be entirely made up and not accurately reflect children’s experience or their strategies for coping with problems. We chose to use both a simplified DMM-AAI discourse analysis (Crittenden & Landini, 2011) and interpretation of the plots and themes of the 14 stories derived from the seven cards. As with all Ainsworth-based assessments, we looked for repeated patterns (as opposed to ratings or other quantitative measures) of discourse functions and story themes and elements. The discourse functions included idealization, preoccupation, denial, and so forth. Story themes included helping someone else, getting into fights, and disastrous endings. Story elements included such things as calling the police to resolve problems. In each case, the markers had to be repeated within and across cards before meaning was attributed. Unresolved traumas and losses were especially hard to identify. These are not apparent in the Strange Situation, whereas in the AAI, they refer to specific historical events. The SAA fell between these assessments with some SAAs containing discourse markers indicative of psychological trauma that could not be assigned specific events. In addition, many of these events were only partially understood by the children who, therefore, could not relate them accurately. This was particularly true for parental conflict, parental infidelity, and parents’ response to losses, especially of other children. Modifiers were identified from specified discourse markers, aspects of story plots or themes, and non-verbal actions. Non-verbal action was noted either by the interviewer (e.g. “You looked really sad when you said that. Did you feel sad?”) or added by the transcriber (intense coughing, scraping of the microphone so speech couldn’t be heard).
Refining and fine-tuning the emerging SAA Over a period of several years, clinicians met in small groups to code and discuss SAA transcriptions. Slowly, in a recursive process that was informed by clinicians, the discourse analysis was refined. The goals were to devise an assessment procedure that appealed to children and a classificatory method and system that differentiated between well-functioning and troubled children and, in addition, revealed important clinical differences among troubled children. More than 50 cases were studied in residential clinical seminars. Other cases were examined by email. A guide was written that addressed both discourse and thematic content in six memory systems (procedural, imaged, semantic, connotative language, episodic, and concrete reflective functioning), plus the somatic non-verbal notes. These were used to define a strategy with, possibly, unresolved traumas or losses and modifiers.
Validating the SAA A plan to validate the SAA Once the goal of engaging children was met and clinically relevant information was identified on a case-by-case basis, it was time to validate the SAA. An optimistic 5-year plan to assess coder reliability, classification validity, and clinical utility was drawn up. Studies were planned to assess (a) whether the SAA discriminated risk from non-risk children (in terms of child diagnosis, clinical measures, and parent functioning), (b) whether there was continuity in children’s strategies from late preschool to the school years, and (c) whether the SAA predicted differences in future functioning.
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Discriminating risk from non-risk Kasia Kozlowska gathered the first set of SAA data on an Australian set of normative children and children referred to child psychiatry at a children’s hospital. The SAAs of these children demonstrated both discriminant validity and also a relation between child and parent psychiatric diagnoses. Uniformly, diagnosed children had parents with one or more psychiatric diagnoses (Crittenden, Kozlowska, & Landini, 2010). Two small, possibly idiosyncratic, results were also found: (a) two normative children had SAAs with “clinical” classifications—in one case, the father had recently been attacked at home, and in the other, the parents divorced within the year and (b) two clinical children had SAAs that classified as “B”—both were approaching discharge after a successful course of treatment. If these findings hold in larger samples, they suggest what the SAA can add to what professionals know. The finding regarding risk versus non-risk was replicated by Kwako, Noll, Putnam, and Trickett (2010) on an American sample; Crittenden, Robson, and Tooby (this issue) on a British sample; and Nuccini, Paterlini, Gargano, and Landini (this issue) on an Italian sample. Strikingly, the greatest differences were not in protective attachment strategy, but rather in depression and unresolved trauma. This suggests that non-B strategies can be adaptive when not disrupted by modifiers or traumas.
Stability of strategy One way to feel confident about the attachment strategy identified by a new assessment is to compare it to the attachment strategy derived from a well-validated assessment. Relying on the validity of the Preschool Assessment of Attachment (PAA, see Farnfield, Hautamäki, Nørbech, & Sahhar, 2010), a sample of 5.5-year-old children was gathered. They and their mothers participated in the Strange Situation for preschool-aged children (Crittenden, 1992), and then 6 months later, the SAA was given to the children and the AAI to the mothers. Concordance between PAA and SAA classification was high (Crittenden et al., this issue). It was notable, however, that the SAA classifications contained detail about psychological trauma and depression that could not be derived from the PAA. As expected, this occurred primarily in clinical cases, but again, some normative children appeared to be troubled. Epidemiologically, this would be expected in about 20–30% of cases (Dilling, Weyerer, & Castell, 1984; Hagnell, Öjesjö, Otterbeck, & Rorsman, 1994; Kessler, 1994; Roberts, Attkisson, & Rosenblatt, 1998; Rutter & Rutter, 1993). Shari Kidwell and her colleagues replicated and extended the PAA-to-SAA relation from 4 to 11 years (Kidwell et al., this issue).
Construct validity The central DMM construct that underlies anxious attachment is that protective attachment strategies are needed when individuals are exposed to danger that they cannot manage by themselves (Crittenden, 1999). Several of the SAA studies measured children’s exposure to danger; in all of these studies, greater endangerment was associated with more extreme self-protective attachment strategies. Of course, the relation was not an equivalence because information processing connected exposure to danger with self-protective strategy. Thus, when the danger was in a child’s zone of proximal development, children protected themselves and did not experience trauma. Similarly, when children and parents had completed a successful course of psychotherapy, psychological trauma was no longer observed.
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Kozlowska’s Australian sample, Robson and Tooby’s UK sample, and the American sample of Kwako and her colleagues all supported the relation of exposure to danger with extreme and sometimes ineffective self-protection and all had exceptions that were comprehensible when examined individually.
Clinical utility Applying the results of an assessment in real lives, as opposed to grouped and anonymous research data, requires strong evidence of discriminant validity, differentiable subpatterns within the clinical risk group, and high coder reliability (sustainable on a case-by-case basis). Kozlowska and her colleagues have explored the functioning of children with conversion disorders using the SAA in a series of papers (Kozlowska, Scher, & Williams, 2011; Kozlowska & Williams, 2009). They found that conversion disorders were heterogeneous with three types (A, C, and A/C), reflecting different neurobiological processes for coping with stress and requiring different forms of treatment. Nuccini and her colleagues explored the relation of very low birth weight to children’s attachment strategies (Nuccini et al., this issue). They found that low birth weight children used extreme self-protective strategies, particularly feigned helplessness. There was no difference in rates of psychological trauma, but prematurely born children had traumas about illness, whereas full-term children had traumas about family problems. Two case studies presented the use of the SAA to understand attention deficit hyperactivity disorder (ADHD) (Crittenden & Kulbotten, 2007) and fabricated illness (Kozlowska, Foley, & Savage, 2012). In both cases, parents’ concerns were central to children's problems. In the ADHD case, it was parental conflict around infidelity; in the facticious illness case, it was parents’ unresolved fear of loss.
Limitations These nine studies bode well for the validity, reliability, and utility of the SAA, but they also highlight limitations and gaps. Coder reliability was achieved in all studies, but most people who were trained did not become reliable. This suggests that assessing attachment requires specific expertise, possibly in both individual assessments and also the theory of attachment underlying the assessment. Furthermore, the events that elicited children’s strategies were not clear, nor was parental input. A detailed family history and information about parental attachment were needed to clarify the meaning of children’s SAAs. Other important topics have not yet been addressed. What about siblings? We will offer data in Part 2 of this Special Section on siblings. Is there anything the children can’t say in words? We will explore the relation of children’s family drawings to their SAAs, expecting that images will convey information that words cannot. What about the parents? We will offer data comparing mothers’ AAIs to their children’s SAAs. And specific disorders? Slowly, in the coming years, we hope to explore several important disorders in formal and case studies. We hope to identify a set of underlying intra- and interpersonal processes, as opposed to symptoms, that could be revealed through assessment and addressed through treatment.
Understanding children I began by saying it was difficult to understand distressed children. These studies support that statement: children’s communication is filled with their misunderstandings, lack of information, and need to protect themselves and their parents from what they know (or fear that they know). Nevertheless, children try, in their own way, to explain how they understand their lives. The
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combination of discourse and plot/theme analysis across seven threats, with fantasy and recalled episodes for each, can reveal the complex inner worlds of school-aged children, particularly those who feel most threatened. If there is a bottom line to an incomplete program of research, it is that children with behavioral, psychiatric, and unexplained somatic symptoms feel threatened. Decoding their narratives, combined with similarly decoded information from their parents’ AAIs and details of family history, can reveal processes that make sense for everyone: the parents who care so much for their distressed children, the children themselves, and the professionals who seek to relieve families’ suffering. If the SAA contributes to understanding children and points to the need for similar understanding of their parents, it will offer much-needed hope to both families and professionals. References Crittenden, P. M. (1992). Quality of attachment in the preschool years. Development and Psychopathology, 4, 209–241. Crittenden, P. M. (1999). Danger and development: The organization of self-protective strategies. In J. I. Vondra, & D. Barnett (Eds.), Monographs of the Society for Research on Child Development: Series No. 258. A typical attachment in infancy and early childhood among children at developmental risk (Vol. 64, pp. 145–171). Malden, MA: Wiley-Blackwell. Crittenden, P. M. (2015). Raising parents: Attachment, representation, and treatment (2nd ed.). London, England: Routledge. Crittenden, P. M., Kozlowska, K., & Landini, A. (2010). Assessing attachment in school-age children. Clinical Child Psychology and Psychiatry, 14, 185–208. Crittenden, P. M., & Kulbotten, G. R. (2007). Familial contributions to ADHD: An attachment perspective. Tidsskrift for Norsk Psykologforening, 10, 1220–1229. Crittenden, P. M., & Landini, A. (1999). Administering the school-age assessment of attachment. Unpublished manuscript. Crittenden, P. M., & Landini, A. (2011). Assessing adult attachment: A dynamic-maturational approach to discourse analysis. New York, NY: W. W. Norton. Crittenden, P. M., Robson, K., & Tooby, A. (2015, this issue). Validation of the School-age Assessment of Attachment in a short-term longitudinal study. Clinical Child Psychology and Psychiatry, 20(3), 348–365. Dilling, W., Weyerer, S., & Castell, R. (1984). Psychische Erkrankungen in der Bevölkerung. Stuttgart, Germany: Enke. Farnfield, S., Hautamäki, A., Nørbech, P., & Sahhar, N. (2015, this issue). Dynamic-maturational model methods for assessing attachment. Clinical Child Psychology and Psychiatry, 15, 313–328. Hagnell, O., Öjesjö, L., Otterbeck, L., & Rorsman, B. (1994). Prevalence of mental disorders, personality traits and mental complaints in the Lundby Study. Scandinavian Journal of Social Medicine, Supplementum, 50, 1–77. Hansburg, H. G. (1972). Adolescent separation anxiety: A method for the study of adolescent separation problems. Springfield, IL: C. C. Thomas. Kessler, R. C. (1994). The national comorbidity survey of the United States. International Review of Psychiatry, 6, 365–376. Kidwell, S. L., Sizemore, K. M., Qu, J., Fugate, K. M., Deaton, M. S., & Blevins, M. D. (2015, this issue). Validity of the School-age Assessment of Attachment for moderate-risk, rural early adolescents. Clinical Child Psychology and Psychiatry, 20(3), 366–380. Klagsbrun, M., & Bowlby, J. (1976). Responses to separation from parents: A clinical test for young children. British Journal of Projective Psychiatry, 21, 7–27. Kozlowska, K., Foley, S., & Savage, B. (2012). Fabricated illness: Working within the family system to find a pathway to health. Family Process, 51, 570–587. doi:10.1111/famp.12000
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Kozlowska, K., Scher, S., & Williams, L. M. (2011). Patterns of emotional-cognitive function in pediatric conversion patients: Implications for the conceptualization of conversion disorders. Psychosomatic Medicine, 73, 775–788. Kozlowska, K., & Williams, L. M. (2009). Self-protective organization in children with conversion and somatoform disorders. Journal of Psychosomatic Research, 67, 223–233. Kwako, L. E., Noll, J. G., Putnam, F. W., & Trickett, P. K. (2010).Childhood sexual abuse and attachment: An intergenerational perspective. Clinical Child Psychology and Psychiatry, 15, 407–422. Nuccini, F., Paterlini, M., Gargano, G., & Landini, A. (2015, this issue). The attachment of prematurely born children at school age: A pilot study. Clinical Child Psychology and Psychiatry, 20(3), 381–394. Resnick, G. (1993). Measuring attachment in early adolescence: A manual for the administration, coding and interpretation of the Separation Anxiety Test for 11 to 14 year olds. Unpublished manuscript, Westat, Rockville, MD. Roberts, R. E., Attkisson, C. C., & Rosenblatt, A. (1998). Prevalence of psychopathology among children and adolescents [Special article]. American Journal of Psychiatry, 155, 715–725. Rutter, M., & Rutter, M. (1993). Developing minds: Challenge and continuity across the lifespan. New York, NY: Basic Books. Slough, N. M., Goyette, M., & Greenberg, M. T. (1988). Scoring indices for the Seattle version of the Separation Anxiety Test. Unpublished manuscript, University of Washington, Seattle.
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