Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 1: Cultivating secure bonds with our children during stressful times

(Please stay tuned for Article #2: ‘Parenting during a pandemic’. We will expand on how to nurture these secure attachments with our children.)

By Dr. Linda Uyeda (biography and disclosures) and Dr. Ashley Miller (biography and disclosures) (Members of the Child and Youth Mental Health and Substance Use Community of Practice and the Working Group on Adverse Childhood Experiences)

Linda Uyeda: Disclosures: Engaged in public speaking and has received honoraria. Mitigating potential bias: The information provided about attachment theory and the recommendations outlined are referenced clearly to show where the evidence was obtained.

Ashley Miller: Disclosures: Dr. Miller is the co-author of What to Say to Kids When Nothing Seems to Work: A Practical Guide for Parents and Caregivers. Mitigating Potential Bias: Recommendations are consistent with attachment literature and do not relate specifically to the contents of the book.

What I did before

Twenty years ago, I started my career as a family doctor and, at the same time, I began a family of my own. Initially, I didn’t see the two as being connected. My training as a physician taught me to recognize disease, diagnose and treat illness but it took becoming a parent to understand that strong and nurturing relationships can truly help people heal.

Becoming a first-time parent is stressful and confusing and like many of us, I wasn’t always confident that my intuition was guiding me in the right direction, so I sought evidence to help me along the way. I dove into research on parenting and attended multi-disciplinary conferences on neuroscience and human development and what I found shifted my world. Not only did this information form the basis of my family’s parenting approach but it brought me, full circle, back to my career as a physician. I learned that the quality of my interactions with my patients and with my coworkers had a direct impact on patient outcomes. I was able to make a difference in my patients’ lives when I learned to listen and respond in a new way.

What changed my practice

What drove this change was learning about something called attachment theory and, as important as I think it is, it is not often discussed in general medical circles (1). Attachment theory is a model that illustrates how our earliest relationships help shape our future emotional responses and can influence the quality of all of our relationships. I came to understand that attachment theory is not the same thing as the popular concept of ‘attachment parenting’.

Far from being a “soft approach” or a mandate towards co-sleeping and constant baby-wearing, attachment theory emphasizes the importance of caregiver well-being, presence, and open curiosity towards a child’s evolving needs.

John Bowlby (1907-1990), a British psychiatrist, is largely considered the father of attachment theory. He was a research scientist who brought together concepts from animal studies, systems theory, cognitive psychology, and behaviourism in order to understand that humans develop in the context of their relationships and are not simply closed systems (2). All mammals are hardwired to signal their primary caregivers when hurt, sick or scared, and these signals are called “attachment behaviors”. When human infants or children feel confident that their signals will be met enough of the time, with a consistent caregiving response, their bond with their caregiver is termed “secure”. Those who fear they may not get what they need or who have started hiding their needs even when highly distressed may have an “insecure” attachment relationship. When a parent-child relationship is less secure, children will be more likely to unconsciously turn up the volume on their signals (i.e. angry protest) or turn down the volume (i.e. withdraw and shut down).

Why does this matter?

Insecure attachment (also called insecurity) in infancy has been linked to a host of illnesses in adulthood including mental health problems (anxiety, depression, major mental illness) and physical illness (asthma, COPD, hypertension, cardiovascular disease, etc.) (3,4, 5, 6, 7, 8, 9). This insecurity can also lead to relationship struggles with peers, co-workers, our own children, romantic partners, and even the physician-patient relationship (2,10,11). Securely attached children tend to be better at forming friendships, balancing difficult emotions, problem-solving, and collaborating. They have an inner voice that says, “I’m worthy of love, attention, and being treated well.” Attachment patterns also tend to be transmitted intergenerationally without conscious awareness. However, the transmission of insecure attachment patterns can be mitigated by learning new secure attachment behaviors (12, 13).

Barriers to Secure Attachment:

Most, if not all, parents try their very best to do what they believe is right for their children. Lack of love is almost never the cause of insecure attachment. There are many factors that can get in the way of developing secure attachments with our children including significant parental stress (economic, emotional, and physical), long durations of parent and child separation, and parental history of insecure attachment. The great news is that attachment patterns are not fixed and can be transformed (14, 15). Hope lies in the fact that supporting and buffering parents, as well as small changes in a parent’s responses towards their children, can promote secure attachments. (16, 17, 18)

Relevance to the Current COVID-19 Pandemic:

The COVID-19 Pandemic has put most of us under significant stress and we know that prolonged and heightened stress in adults can be a barrier to secure attachment patterns in children. Children are constantly downloading our emotional states whether we are aware of this or not.

What I do now

Now, more than ever, we need to understand the value of healthy, secure attachment relationships and connection. Our autonomic fight, flight, and freeze responses are subconsciously calmed when we experience secure attachment relationships. What hits home for me as a physician, is that this research shows that a behavioral system (in this case secure attachment) can help protect our biologic systems. What?! So how do we do this for our children and ourselves?

The foundation of creating secure attachments comes from creating a ‘safe haven’ for our children where they can retreat when stress becomes too big for them to handle. Secure relationships also provide a ‘secure base’ from which they can be brave and explore the world. Dr. Daniel Siegel, a child psychiatrist at the University of California, Los Angeles, and Tina Payne Bryson explain this with their 4 S’s of secure attachment in the book, The Power of Showing Up (19):

1. Safe – One of the easiest ways we can create a sense of safety for our children is to change how we speak to them about stressors such as the COVID-19 pandemic. As an example, saying things like, “It’s dangerous if we get together with other families or friends right now,” communicates to our children that ‘the world is a dangerous place’. Instead, we could say, “We are going to follow public health advice in order to keep everyone safe.” In this way, we send the message to our children that my parent keeps me safe. One day, when the dangers of the pandemic are over and the restrictions are lifted, we want our children to believe that the world is a welcoming place where they can safely go and explore.
2. Seen – We create secure attachments with our children and others when we are able to effectively ‘see’ them for who they are and ‘feel’ what they feel. We may not be able to change how difficult this time is for them but we can use empathy and reflections to validate their experience. “You’re feeling really sad about not seeing your best friend right now. This must be really difficult.”
3. Secure – We can support our children by providing them with a sense that we have “got their backs” no matter what. While we may not always agree with their decisions, we will always stick by them. We are better able to do this by keeping ourselves emotionally healthy and balanced. I loved Dr. Jennifer Russel’s recent TCMP article about how to put on our own psychological PPE to protect ourselves and also those around us. When it comes to emotions, we “can’t give what we don’t got”.
4. Soothed – We can’t control the waves of the pandemic and the restrictions that follow escalating numbers but we can help our children manage the difficult feelings and emotions that arise within them. By learning the skills of validation and emotional coaching we can help calm their raw emotions. My body language, my tone of voice, and my calm nervous system can help balance my child’s distress and feelings of anger, sadness, and disappointment.

I have sought ways to change my behaviour to create healthy attachment relationships with my children, husband, friends, coworkers, and patients and it never ceases to amaze me how these relationships have transformed. I have come to understand that in creating these new types of relationships, I have learned to speak and embody a new emotional language. If we were not lucky enough to experience this language as a child, there is hope to learn it at any age. Learning these lessons changed, not only my medical practice but my life… for the better.

Further reading

1. https://www.zerotothree.org
2. https://www.circleofsecurityinternational.com
3. https://www.brazeltontouchpoints.org/
4. https://parentandteen.com

References

1. Rees C. Childhood attachment. Br J Gen Pract. 2007;57(544):920–922. DOI: 10.3399/096016407782317955. (View)
2. Karen R. Becoming Attached: First Relationships and How They Shape Our Capacity to Love. Oxford University Press; 1998. (Request with CPSBC or view with UBC)
3. Puig J, Englund MM, Simpson JA, Collins WA. Predicting adult physical illness from infant attachment: A prospective longitudinal study. Health Psychol. 2013;32(4):409–417. DOI: 10.1037/a0028889. (View)
4. Marks ADG, Horrocks KA, Schutte NS. (2016) Emotional intelligence mediates the relationship between insecure attachment and subjective health outcomes. Pers Individ Dif. 2016;98:188-192. DOI: 10.1016/j.paid.2016.03.038 (View)
5. Mikulincer M, Shaver PR. An attachment perspective on psychopathology. World Psychiatry. 2012;11(1):11–15. DOI: 10.1016/j.wpsyc.2012.01.003. (View)
6. Uchino BN, Eisenberger NI. Emotions in social relationships and their implications for health and disease: Introduction to the special issue of psychosomatic medicine. Psychosom Med. 2019;81(8):676-680. DOI: 10.1097/PSY.0000000000000741 (View with CPSBC or UBC)
7. Farrell AK, Waters TEA, Young ES, et al. Early maternal sensitivity, attachment security in young adulthood, and cardiometabolic risk at midlife. Attach Hum Dev. 2019;21(1):70-86. DOI: 10.1080/14616734.2018.1541517. (View with CPSBC or UBC)
8. Shah PE, Fonagy P, Strathearn L. Is attachment transmitted across generations? The plot thickens. Clin Child Psychol and Psychiatry. 2010;15(3):329–345. DOI: 10.1177/1359104510365449. (View)
9. Hunter JJ, Mauder RJ. Using attachment theory to understand illness behavior. Gen Hosp Psychiatry. 2001;23(4):177-182. DOI: 10.1016/S0163-8343(01)00141-4. (View with CPSBC or UBC)
10. Grich J. (2002). Earned secure attachment in young adulthood: Adjustment and relationship satisfaction. Diss Abstr Int. 2002;62(7-B):3419. (Request with CPSBC or view with UBC)
11. Pearson JL, Cohn DA, Cowan PA, Cowan CP. Earned-and continuous-security in adult attachment: Relation to depressive symptomatology and parenting style. Dev Psychopatholy. 1994;6:359-373. DOI: 10.1017/S0954579400004636. (Request with CPSBC or view with UBC)
12. Spatz Widom C, Czaja SJ, Sepulveda Kozakowski S, Chauhan P. Does adult attachment style mediate the relationship between childhood maltreatment and mental and physical health outcomes? Child Abuse Negl. 2018;76:533-545. DOI: 10.1016/j.chiabu.2017.05.002. (View)
13. Coan JA, Schaefer HS, Davidson RJ. Lending a hand: social regulation of the neural response to threat. Psychol Sci. 2006;17(12):1032-1039. DOI: 10.1111/j.1467-9280.2006.01832.x. (View with CPSBC or UBC)
14. Singh-Taylor A, Korosi A, Molet J, Gunn B, Baram T. (2015). Synaptic rewiring of stress-sensitive neurons by early-life experience: a mechanism for resilience? Neurobiol Stress. 2015;1(1):109-115. DOI: 10.1016/j.ynstr.2014.10.007. (View)
15. Siegel DJ, Hartzell M. Parenting From the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive. 10th ed. New York, NY: Jeremy P. Tarcher/Penguin; 2014. (Request with CPSBC or find with WorldCat)
16. Cohen SD. 3 principles to improve outcomes for children and families. https://46y5eh11fhgw3ve3ytpwxt9r-wpengine.netdna-ssl.com/wp-content/uploads/2017/10/HCDC_3PrinciplesPolicyPractice.pdf. October 2017. (View)
17. Porter L, Martin K, Anda R. A comprehensive model of building community capacity in Washington helped make dramatic reductions in rates of health issues and social problems. https://www.rwjf.org/en/library/research/2016/06/self-healing-communities.html. June 29, 2016. (View)
18. National Scientific Council on the Developing Child. Young children develop in an environment of relationships: Working paper no. 1. https://developingchild.harvard.edu/resources/wp1/. October 2009. (View)
19. Siegel D, Payne Bryson T. The Power of Showing Up: How Parental Presence Shapes Who Our Kids Become and How Their Brains Get Wired. Random House Publishing Group; 2020. (Request with CPSBC or view with UBC)

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Curing Through Connection: A 3-part series on attachment, resilience, and health. Article 1: Cultivating secure bonds with our children during stressful times

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