Attachment & Autism

Attachment & Autism
Sean Bryan, PGY-2 Northern Ontario School of Medicine
Developmental Pediatrics - Academic Hour
October 27, 2015
McMaster University

Thompson Island, Lake SuperiorPhoto: S. Bryan

Objectives
• Medical expert: Develop an understanding of
attachment theory and how it applies to ASD
• Scholar: Describe the present literature on
attachment in ASD

Outline
• Part I: Introduction to attachment theory
• Part II: ASD through the attachment lens
• Part III: Take-home messages

Attachment theory
• John Bowlby and Mary Ainsworth developed a theory of
parent-child attachment describing how and why
attachments form, and what happens when a healthy
attachment does not occur
• Attachment can be described as a strong preference to
be proximal to another speciﬁc person; to be distressed
when apart and comfortable when together
Watson, M. (2002). Theories of Human Development. The Teaching Company.

Why do we need attachments?
• Humans are not as ‘hard-wired’ but rather are ﬂexible,
open to learning
• Flexibility requires a long period of immaturity
• Parenting only occurs in species with long periods of
immaturity
• Nature ensures the parent-child dyad works via a
reciprocal attachment system

What are the beneﬁts of attachments?
• Guarantees basic needs of child are met
• Some psychological, physical, emotional needs of
parents are met in turn
• Sense of security and trust; quells fears
• Social referencing
• Child is primed to learn best from attachment ﬁgures
• Attachment as a model for future relationships

Ethology and the “critical period”
• Bowlby rejected psychodynamic theory in favour of
ethology theory
• Ethology is the studying of animal behavior and
development, with emphasis on adaptive importance
• A critical period is a time in the course of development
when an individual is particularly sensitive to certain
environmental cues and primed to respond to them; they
correspond to key reorganizations of the neural system 

Imprinting & releasing mechanisms
• A newborn animal responds to the movements of another
object and forms neurological connections or patterns
• Cues of color, patterns, or actions signal to others to
respond in a certain way; these signaling patterns are
called innate releasing mechanisms

Not just a pretty face
• Immature phenotypes with large
heads, eyes, and soft, rounded,
non-angular features are common
to many species where stronger
parenting is required
• Lorenz described a set of well-
conserved releasing mechanisms
he called ‘babyishness’
• Imparts an automatic nurturing
instinct, even across species

Human releasing mechanisms
• Babies respond to tactile stimuli, human faces and especially eyes,
smiling, and prefer and are calmed by the sound range of the
human voice (particularly female voices). Babies and adults have
parallel, reciprocal responses. Age-speciﬁc examples include:
• First 3 weeks: grasping, clinging, cuddling, crying
• 7-8 weeks: tracking, eye contact, responsive smile; ‘7-week shift’
• 3-4 months: turn-taking, peek-a-boo
• 5-6 months: speciﬁc preferences for certain people
• 7-12 months: separation fear, stranger fear

Safe! The secure base
• Ainsworth developed the concept of a secure base in
infant attachments
• From this secure base, the child can then explore, take
risks, and in fact, behave more independently
• To assess the type of attachment that had formed
between a parent and child, Ainsworth developed a
technique she called the strange situation task

https://www.youtube.com/watch?v=QTsewNrHUHU

Types of infant attachment
• Avoidant attachment: appears to ignore mother; shows
minimal distress on her leaving; avoids her on reunion;
seems detached from her mother
• Secure attachment: distress on mother leaving; seeks her
proximity, affection, and contact on return; baby shares
feelings easily; is readily comforted; most children show
this type
• Anxious-ambivalent/resistant attachment: baby
inconsistent in distress/reunion responses; may move
toward mother then away again on reunion; may appear as
if she is trying to punish mother

Takes two to tango
• Child’s innate temperament informs attachment
• Some children are markedly sensitive, responding to
new aspects of their environment with wariness,
caution, and inhibited behaviour; they tend toward
anxious-ambivalent/resistant attachment
• Other kids who are extremely uninhibited are more
likely to exhibit avoidant attachment
• Consensus that attachment depends on both child
and parental factors

Implications for attachment types
• Good evidence for strange situation classiﬁcation predicting
attachment type and outcomes, including:
• secure — > more secure and normal peer friendships during
preschool years
• insecure —> behaviour problems more likely; especially true
of resistant/ambivalent type
• avoidant —> depression and mood disorders more likely
• Longitudinal studies show that attachment type tends to persist
into adulthood, affecting parenting and spousal relationships

The “internal working model”
• Bowlby proposed that during the ﬁrst two years of life,
children develop an internal working model of each of
their primary attachment relationships
• The model as proxy for attachment ﬁgure; a ‘security
blanket’
• When the attached person is not present, the child’s
secure base is also unavailable; therefore, the child feels
insecure

The “internal working model”
• More than a secure base, a model for subsequent
relationships (contentious), similar to Freud’s ‘transference’
• Tendency to repeat the same patterns of parenting, and of
interacting in intimate relationships, that they experienced
or witnessed as children
• Consider the
intergenerational effects
of residential schools on
Aboriginal people vis-a-
vis parenting

Fort Severn First Nation,
Hudson Bay
Photo: S. Bryan

Fort Severn First Nation,
Hudson Bay
Photos: S. Bryan

Autism spectrum disorder (ASD)
• A lifelong, complex neurodevelopmental disorder that
severely impairs social interaction
• Core symptoms include abnormal or unreciprocated
interpersonal and emotional interactions, disordered social
communication, and repetitive and stereotypic behaviors
and restricted interests
• Thought to occur in the latter part of the ﬁrst year of life,
although the ﬁeld is searching for neurobiological
expressions of ASD in even earlier periods of development
Schore, A. N. (2014). Early interpersonal neurobiological assessment of attachment and autistic spectrum disorders. Frontiers in Psychology.

Attachments do form in ASD
• Despite the signiﬁcant social impairments
associated with ASD, research shows that autistic
children are capable of forming attachment
relationships with their caregiver
• Roughly 50% of autistic infants are found to be
securely attached
• That said, in comparison to typically-developing
children, secure attachments are signiﬁcantly
underrepresented (medium effect size) in ASD
Rutgers, A. H., & Kranenburg, M. B. (2004). Autism and attachment: a meta‐analytic review. Journal of Child Psychology and Psychiatry 45:6.
Carlson, E. A., Sampson, M. C., & Sroufe, L. A. (2003). Implications of Attachment Theory and Research for Developmental-Behavioral Pediatrics.
Journal of Developmental & Behavioral Pediatrics, 24(5), 364.

Attachments do form in ASD
• Attachment insecurity is correlated with severe ASD
symptoms and the degree of co-morbid intellectual
disability
• Though the Strange Situation task was found to be
essentially appropriate for use in ASD, there are
important methodological differences
• eg. 3-4 yo tested, modiﬁed protocols
Rutgers, A. H., & Kranenburg, M. B. (2004). Autism and attachment: a meta‐analytic review. Journal of Child Psychology and Psychiatry 45:6.

A Parent-Mediated Intervention That Targets Responsive
Parental Behaviors Increases Attachment Behaviors in
Children with ASD: Results from a Randomized Clinical Trial
• RCT evaluating the efﬁcacy of Focused Playtime
Intervention (FPI) in a sample of 70 children with ASD
• The authors previously showed this parent-mediated
intervention to signiﬁcantly increase language gains in
children with ASD (Siller et al., 2003)
• Note this is the same study group
Siller, M., Swanson, M., Gerber, A., Hutman, T., & Sigman, M. (2014). A Parent-Mediated Intervention That Targets Responsive Parental Behaviors
Increases Attachment Behaviors in Children with ASD: Results from a Randomized Clinical Trial. Journal of Autism and Developmental Disorders,
44(7), 1720–1732.

• 70 children (64 boys and 6 girls); 2-6 yo; California
1. the child was 6 years or younger when entering the study
2. the child had previously been diagnosed with ASD (conﬁrmed with
Autism Diagnostic Interview-Revised)
3. the child showed limited or no use of spoken language (generally fewer
than 25 words and no phrases based on parent report)
4. the child’s mother was ﬂuent in English and willing/available to
participate in all assessment and intervention sessions, and
5. the family lived within a reasonable travel distance from the research
lab (generally less than 90 min)
44(7), 1720–1732.

• FPI is a parent education program that involves 12 in-
home training sessions (one session per week for 12
weeks, 90 min per session) and follows a standardized
intervention manual
• Initially developed to test the causal mechanisms in early
responsive parental behaviors and children’s
subsequent gains in spoken communication
44(7), 1720–1732.

• Parent and interventionist developed an understanding of
the child’s communication skills and strategies to arrange
the play environment in ways that are conducive to play
• Central to FPI was creation of a playtime routine that
could feasibly be incorporated into the family’s daily
schedule
• Emphasis was on coordinated attention, shared way of
using the toys, and gradual shifting of responsibility for
initiating and maintaining the shared encounter to child
44(7), 1720–1732.

• 3 time points: baseline, exit, and follow-up (12 mo)
• Attachment measured via both a separation-reunion episode
and by evaluating the mother’s perception of attachment
• Staff involved in coding and assessments were kept blind to
the group assignment of participants
• Good analysis of potentially confounding variables; eg SES,
maternal age, country of birth, etc
• Intention-to-treat
44(7), 1720–1732.

44(7), 1720–1732.
J Autism Dev Disord (2014) 44:1720–1732 1729
• Signiﬁcant main effect of treatment group allocation on gains in parent
reported attachment behaviors (MPCA scores), t(48) = 3.0, p < .01
• Signiﬁcant main effect of treatment group allocation on gains in observed
attachment behaviors (mean), t(54) = 2.0, p < .05

• FPI resulted in greater increases in attachment-related behaviors
for children with ASD versus controls (no FPI); speciﬁcally, avoidant
behaviours improved
• However, at follow-up results inconclusive: did the FPI group improve
or did the controls worsen with respect to avoidant behaviours?
• Future research should investigate whether FPI increases not just the
quantity of attachment-related behaviors, but also the quality of
children’s attachment relations
• Both longitudinal and experimental research designs should be used
to investigate the long-term outcomes associated with individual
differences in the early attachment relations in ASD
44(7), 1720–1732.

Attachment, ASD & the Oxytocin Connection
• Children with ASD had lower baseline oxytocin in one study;
oxytocin normalised and remained high during social contact,
but fell to baseline shortly thereafter
• Greater oxytocin levels with secure mother-infant attachment
and improved prosocial interactions in ASD were noted after a
single dose of oxytocin
• An oxytocin SNP has been linked to sensitive parenting,
promotion of social afﬁliative behavior and ASD
• However, recent RCTs of oxytocin for ASDs have had negative
ﬁndings, both in adults and children
Creswell KG et al. OXTR polymorphism predicts social relationships through its effects on social temperament. Soc Cogn Affect Neurosci 2014 Oct 16; [e-pub ahead of print].
Feldman, R., Golan, O., Hirschler-Guttenberg, Y., Ostfeld-Etzion, S., & Zagoory-Sharon, O. (2014). Parent-child interaction and oxytocin production in pre-schoolers with autism spectrum disorder. The British Journal of
Psychiatry : the Journal of Mental Science, 205(2), 107–112. http://doi.org/10.1192/bjp.bp.113.137513
Carter, C. S. (2005). The chemistry of child neglect: do oxytocin and vasopressin mediate the effects of early experience? Proceedings of the National Academy of Sciences of the United States of America, 102(51),
18247–18248. http://doi.org/10.1073/pnas.0509376102
Gordon I et al. Oxytocin enhances brain function in children with autism. Proc Natl Acad Sci U S A 2013 Dec 2; [e-pub ahead of print].

Kalalau, HawaiiPhoto: S. Bryan

Attachment-related intervention
• In general, intervention research indicates that,
especially for high-risk populations, intervention
must begin early, be comprehensive, involve
caregivers directly, address emotional aspects of
the caregiving relationship, and, most importantly,
ensure a safe, nurturing therapeutic environment

• Comprehensive evaluations including a
psychosocial history, direct behavioral
observations, and child self-report are needed to
identify relationship strengths and vulnerabilities
and to plan case management
• Relevant background questions concern
experiences of separation, loss, abuse, and
neglect, and attachment-related behavior

Observational markers include:
• the lack of or distorted secure base behavior (i.e., infrequent visual or
physical ‘‘checking in’’)
• inability to engage in exploration (i.e., extreme inhibition, fearfulness,
or dependence)
• extreme distress or lack of distress on caregiver separation
• extreme aggression or failure to establish interaction with a caregiver
• extreme oscillations in behavior
• excessive familiarity with strangers

Key take-home messages
• Despite pervasive deﬁcits in social, affective, and communicative
behaviors, the attachment behaviors of children with ASD show
striking similarities to those of typically developing children,
with severity of ASD symptom and co-morbid intellectual disability
associated with attachment insecurity
• Given the protean etiologic and phenotypic nature of ASD, caution
should be exercised when seeking to apply this clinically
• Neurobiologically-informed early intervention that considers
attachment could impact care of patients with ASD and their families
• As our understanding of how interventions affect attachment-related
outcomes grows, we will be better able to guide families about
program choices

• Alves, E., Fielder, A., Ghabriel, N., Sawyer, M., & Buisman-Pijlman, F. T. A. (2015). Early social environment affects the endogenous oxytocin system: a review
and future directions. Frontiers in Endocrinology, 6, 32. http://doi.org/10.3389/fendo.2015.00032
• Buchheim, A., Heinrichs, M., George, C., Pokorny, D., Koops, E., Henningsen, P., et al. (2009). Oxytocin enhances the experience of attachment security.
Psychoneuroendocrinology, 34(9), 1417–1422. http://doi.org/10.1016/j.psyneuen.2009.04.002
• Capps L., Sigman M., Mundy P. (1994). Attachment security in children with autism. Dev Psychopathol. 6:249–261.
• Carlisle, G. K. (2014). The Social Skills and Attachment to Dogs of Children with Autism Spectrum Disorder. Journal of Autism and Developmental Disorders,
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• Carlson, E. A., Sampson, M. C., & Sroufe, L. A. (2003). Implications of Attachment Theory and Research for Developmental-Behavioral Pediatrics. Journal of
Developmental & Behavioral Pediatrics, 24(5), 364. http://doi.org/10.1016/j.pain.2011.09.011
• Carter, C. S. (2005). The chemistry of child neglect: do oxytocin and vasopressin mediate the effects of early experience? Proceedings of the National Academy
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• Feldman, R., Golan, O., Hirschler-Guttenberg, Y., Ostfeld-Etzion, S., & Zagoory-Sharon, O. (2014). Parent-child interaction and oxytocin production in pre-
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Yellowstone NP, Wyoming
Thank you!
Sean Bryan
PGY-2 Pediatrics
NOSM
sean.bryan@nosm.ca
Photo: S. Bryan

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