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Book Forum: CHILD PSYCHIATRY   |    
Attachment Disorganization
WILLIAM M. KLYKYLO, M.D.
Am J Psychiatry 2001;158:978-978. doi:10.1176/appi.ajp.158.6.978
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Dayton, Ohio

Edited by Judith Solomon and Carol C. George. New York, Guilford Publications, 1999, 420 pp., $43.00.

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This volume of moderate size but great detail is "dedicated with love and respect to the memory of Mary D. Salter Ainsworth" and is a worthy tribute to her. Ainsworth was truly the mother of attachment research, and she inspired the work of the editor-authors, who are now themselves leaders in this field. The theoretical propositions of John Bowlby anticipated today’s understanding of the emotional reciprocity of parent-infant relations and of its evolutionary basis. Ainsworth, in her development of the Strange Situation procedure, provided an empirical template for describing and measuring the attachment that Bowlby theorized. In doing so, she precipitated a torrent of clinical and scholarly work that has utterly changed the way in which we view early parent-child interactions. We see life’s first relationships as informed not merely by parental motivation but also by the ongoing need and capacity of infants for secure attachment.

The original Ainsworth model posited that there are three persistent patterns of attachment—secure-attached, insecure-avoidant, and insecure-resistant—and that these could be identified by the Strange Situation procedure, wherein an infant, over seven 3-minute episodes, is variously separated and reunited with the mother and a stranger. The degree to which these modes persist, whether the "insecure" modes may convey a selective advantage in some settings, how much they predict about later life, and what they say about such phenomena as attachment to inanimate objects or locations have been matters of controversy, which this volume does not address in much detail. It does include a very brief introduction to the work of Bowlby, which may not be accessible to the reader entirely new to this area. In general, this volume presupposes both some familiarity with and acceptance of this model. Given its persistent utility, this is a fair demand—no other model has yet risen to match it, either in heuristic value or as a stimulus for research.

The contents of this book arise from a difficulty that even enthusiastic supporters of the Ainsworth classifications noticed for many years: the appearance of infants who did not fit well into any of the original three patterns. Some infants respond to absence and reunion not with pleasure (secure-attached), avoidance (insecure-avoidant), or even anger (insecure-resistant). Rather, they are disorganized: inconsistent, disoriented, confused, suddenly changing, and jittery with interrupted movements and constricted affects. Judith Solomon and her colleague Mary Main first formally identified this fourth pattern in the mid-1980s; this volume is a detailed compilation of the work that their addition to the Ainsworth model has stimulated.

The book is divided into four parts. In The Etiology of Attachment Disorganization, the contributors first discuss how the phenomenon of disorganized attachment relates to Bowlby’s work, suggesting that it is implicit in his theory. Subsequent chapters address how parental hostility, frightening behavior, and loss may lead to disorganization, offering theoretical and empirical perspectives. It is not surprising to learn that disorganized attachment is seen less often in normotypic populations than in maltreated groups. A stimulating chapter considers the psychobiological aspects of disorganized attachment: infant cardiac responsiveness and adrenocortical activity and maternal experience of trauma and depression.

In the second section, Social and Cognitive Sequelae of Attachment Disorganization, case reports and prospective studies suggest that negative consequences of disorganized attachment may include both social and cognitive problems in school-age children. I found this both fascinating and alarming. The third section addresses atypical populations, including neurologically impaired and malnourished children. The work cited here suggests that there may be multiple identifiable patterns of disorganized attachment with different etiologies.

Part 4, Adult and Clinical Applications, may be the most interesting to the nonscientist reader. Carol George and her colleagues describe their Adult Attachment Interview and Adult Attachment Projective instruments, which identify four adult patterns of attachment: secure, detached, preoccupied, and unresolved. Another chapter considers the relation of attachment disorganization to dissociation. Brief mention is made of borderline pathology in this context, certainly a stimulating idea. Perhaps the most useful chapter of all to clinicians, especially child and adolescent psychiatrists, is Jacobsen and Miller’s "Attachment Quality in Young Children of Mentally Ill Mothers." They consider "a profound dilemma: Children of mentally ill mothers may be at high risk while remaining with their mothers, and also when separated from them."

This is not a book of clinical procedures, although the experienced clinician will draw useful insights from its contents. The detail and considerable amount of data may be daunting to the general reader. This volume, however, will be valuable to clinicians who regularly work with young children and their parents, and to psychotherapists concerned with the genesis of attachment problems in adult patients. It is an essential resource for any researcher in this area, and it should be placed in every medical library.

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