F. Lecannelier
Facultad de Ciencias Médicas
Facultad de Ciencias Médicas
Universidad de
Santiago de Chile
Santiago, Chile
Attachment is a concept that was introduced in
psychoanalysis and child psychology approximately 75 years ago by Bowlby (1969). It is a
concept that is rooted in Biology, and in Evolution
Theory as well as Ethology (the science of animal behavior). The basic concepts are that a baby
will develop a preferential relationship with a few
caregivers and will go to them for protection and
nurturance, particularly when there is distress.
The attachment behavior of the infant is observable after the sixth month of life and the “height”
of attachment is observable readily around the
first birthday of the baby. The infant will only go
to the caregiver if the latter has been sensitive and
responsive to the needs of the child. As soon as
the infant establishes contact with the caregiver
he or she will feel reassured and the stress will
diminish quickly.
In terms of research, there is little research
based on direct observation of the attachment
patterns in naturalistic environments, despite
the fact that Ainsworth made her initial observations with mothers and babies in Uganda
(Ainsworth et al. 1974). There are multiple
studies looking at attachment patterns based on
the “strange situation” which is the basic
research paradigm in the scientific literature. However, little can be said about “naturalistic”
patterns of responsiveness by caregivers and
behavior by the infant, which may or may not be
strongly influenced by culture.
When one looks at the “strange situation,” a
cultural issue comes to the fore. In some cultures,
babies around one year of age never have been
around a stranger, while in others the infant has
been in a child care center and is used to the presence of people that are not his immediate primary
caregivers (mother, father, grandmother, etc.). It
is possible that if one applies the research protocol of the strange situation, babies with less exposure to strangers might exhibit more distress
upon separation and might get more upset. They
may be more difficult to console after the separation which may be experienced as very stressful
for such a child.
A further question that has been explored in
the literature is whether infants who spend time
in child care settings might have more insecure
patterns of attachment than children that are not
exposed to such extensive daily separations. It
appears that prolonged hours in day care, and
when the facility is inadequate or the caregivers
do not respond to the signals of the child, this
might alter the behavior of the infant at least in
the child care center and might have a negative
effect in the security of attachment of the infant
in general. From the few studies available, it is
hard to derive many conclusions about different
cultures and their practices.
Here, we focus on an intervention program
to foster the development of secure attachment
and caregiver sensitivity in a South American
country, Chile (Lecannelier, 2012).
Until 15 years ago, early childhood was a
neglected topic in Chile (and across South
America) (Raczynski 2006) with scarce development of research, intervention, and public
policies. Models focused on early attachment
and sensitive caregiving were not included in
prevention programs used in the diverse contexts of children’s lives (public health, nursery
school, kindergarten, hospitals, and others).
Nevertheless, this lack of awareness and sensitivity to this fundamental stage in life started
to change with the implementation of the child
protection system called Chile Crece Contigo
(Chile Grows with You), whose purpose is to
provide an integrated social protection system
for young children and their families from
pregnancy to 5 years old (Infancia 2006). This
national system (which is a law promulgated
by the Chilean congress) offers a wide variety
of services that include assessment and intervention, information, and material resources
for children and their families that receive
public healthcare assistance (70% of children
in Chile). Social agents and political actors
began to consider this topic as a priority and
understand the urgency of early intervention
for children and their caregivers at an economic, biological, socio-emotional, and cultural level (Heckman 2006; Narvaez et al.
2013; Polan and Hofer 2008; Shonkoff and
Deborah 2000).
Here, we review main programs that have been
implemented nationwide, aspects of the process
of implementation, and level of impact
(Lecannelier, 2014d). The nucleus of the intervention model used for all the programs is represented in the acronym AMAR which stands for
Attention, Mentalization, Self-Mentalization and
Regulation.*
*A.M.A.R means TO LOVE in English
Theoretical and Empirical Bases
of the AMAR Model
Survival and Emotional Security
As the “Ultra social beings” (Hrdy 2009)
humans require the development of a sense of
emotional security provided by others (Bowlby
1969; Cassidy and Shaver 2008; Lecannelier
2006a, b, 2009; Sroufe et al. 2006). When confronted with stressful or threatening situations
the infant will innately tend to look for the protection of an adult “who is bigger, stronger, wiser
and kind…” (Bowlby 1969). This early attachment system exists in a regulatory intersubjective
space. The success of the efforts will lead to a
sense within the child (and caregiver) of emotional security.
There are six main determinants that influence
on infant emotional security:
- Stability (continuous permanence of caregivers and no prolonged separations or frequent changes in the caregiving environment)
- Continuity (amount of continued time with the caregiver)
- Specificity (existence of a limited number of significant caregivers)
- Predictability (in environmental habits and regulation strategies by caregivers),
- Commitment to caregiving (understood from the perspective of caregiver investment or level of resources that the caregiver invests in the development and survival of the child)
- Acknowledgement, regulation of stress (use of caregiving strategies that don’t trigger feelings of threat and danger from the caregivers).
These conditions are summarized by the term
Environment of Evolutionary Adaptedness or
EEA (Bowlby 1969; Schore 2013). When the
caregiving environment is lacking significantly in
these characteristics, the infant experiences less
emotional security and will deploy a wide range
of [defensive] strategies to regulate personal and
emotional bonds to re-establish security.
An external observer may consider these
strategies as insecure or pathological, but from the
child’s experience they are adaptive modes (according to available internal and external resources)
that reflect a best effort attempt to seek security in
the world and with others (Lecannelier 2013a).
The purpose and rationale of the AMAR programs is to re-establish (or strengthen) adequate
levels of emotional security in the infant (especially in stressful situations). The achievement of
these aims requires that the caregiver develop specific capacities. From the perspective of the
AMAR model this is applied using what we call
the “Respectful Care System” (Lecannelier 2016).
Emotionally Secure Respectful Care
System (CRESE)*
During recent years (Small 2002; George and
Solomon 2008), this type of care has received
several names such as Positive Parenting
(Rodrigo et al. 2007), Attachment Parenting
(Sears and Sears 2001), and Attachment Focused
Parenting (Hughes 2009). We proposed an extension to these notions with our concept “Respectful
Caregiving System,” in the sense that emotional
security does not only come from parents
(although it usually does) but also from alternative caregivers (e.g., infants in child care or institutionalized infants), from educators (preschool
educators), or even from institutions (schools,
hospitals, early institutionalization centers)
(Lecannelier 2014b).
This Respectful Caregiving System has a
number of identifiable inter-locking characteristics (Lecannelier 2016, 2019). The first involve
seeing the infant’s distress signals as serving a
bonding function—as if the infant is saying “I
can’t do this on my own, I need your help.” The
next principle of caregiving is the need to “hold
the child in mind,” i.e., the child’s expressions of
stress need to be legitimized, accepted, understood, and valued (Hughes and Baylin 2012).
Tied into this task is the caregiver’s need to recall
the child within him- or herself. The adult should,
above all develop a mental/emotional attitude to
“keep the child’s mind in mind” (Bateman and Fonagy 2011; Midgley and Vrouva 2013). This
attitude must, again, be used to empathize with,
and understand (rather than control), the behavior
and reactions of children (Hughes and Baylin
2012; Siegel and Hartzell 2013). This mental
attitude of empathy and mentalization leads to an
emotional and cognitive stance that operates
under an ethical decree of “do not do anything to
children that you would not like done to you.”
Finally, stressful situations, or the immediate
aftermath of distressful situations, are the appropriate moment to establish respectful care: on
the one hand, it enables the regulation of an
appropriate manner for children’s reactions and
behaviors, and on the other it allows for adults
modelling diverse socio-emotional learning strategies (self-regulation, emotional understanding
and expression, communication with adults, how
to handle interpersonal conflicts and others
(Denham and Burton 2004)). Therefore, stressful
situations are the best moments for significant
learning of socio-emotional strategies (Massie &
Campbell, 1978) that go far beyond using verbal
and cognitive instructions (Dozier et al. 2015;
Lecannelier & Zamora, 2013; Lecannelier et al.
2010).
*In Spanish, C.R.E.S.E also sounds like “grow”
Elements of the AMAR Model
The AMAR model was inspired by established
attachment-informed intervention programs,
such as Biobehavioral Catch-Up by Mary Dozier
(Dozier et al. 2005, 2006; Bick and Dozier 2013);
Minding the Baby by Arieta Slade (Slade et al.
2005; Slade 2007), Mentalization-Based
Treatment by Peter Fonagy and collaborators
(Bateman and Fonagy 2011: Allen and Fonagy
2006); Video-Feedback Intervention to Promote
Positive Parenting (VIPP) by Femmie Juffer,
Marian J. Bakermans-Kranenburg, and Marinus
van IJzendoorn (Juffer et al. 2007), Circle of
Security Project (Cooper et al. 2005; Powell et al.
2013), and programs on Socio-Emotional
Learning (SEL) in preschool education (Denham
and Burton 2004).
Four core capacities are promoted by the
AMAR programs as shown below in Fig. 11.1:
Attention is listed first as attending or observing
is the first requirement for any learning or relearning. The process of paying attention on the
observable processes of behaviors and reactions
of the child, especially during stressful moments,
noticing the infant’s non-verbal, verbal, and temperamental processes with the goal of recognizing the individuality of his experience (Ainsworth
et al. 1974).
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Mentalization is a procedural cognitive and
emotional skill (i.e., there is no voluntary control) oriented to explain and understand the
behavior of others by inferring and attributing
mental states (Baron-Cohen et al. 2013; Bogdan
1997; Fonagy and Target 1997; Lecannelier
2009; Oppenheim and Koren-Karie 2012). It
includes thinking about:
What the child may be thinking in stressful situations (emotional states).
What the child may be thinking or imagining or
remembering, etc., (mental states).
What the child may need and express through
his/her behavior and reaction to a stressful
situation (what we call the “adaptive behavioral
function”).
This mentalization activity must be carried out
with a positive attitude and a willingness to never
a priori infer negative actions (“what the child
does is manipulating”) or discredit (“he/she is anaggressive child”), being self-referential (“you
are crying just to annoy me”). Other responses
are making the child feel guilty (“if you cry no
one is going to love you”), making him or her feel
threatened (“if you don’t calm down I am going
to punish you”), ridiculed (“don’t cry like a
baby”), rejected (“I won’t take you in my arms
if you have a tantrum”), or use psychological
prescriptions (“learn to control your behavioral
disorder”).
The aim is to “understand the child from the
child’s point of view and not the adult’s” without
falling into negative attributions (Bateman and
Fonagy 2011; Lecannelier 2014a).
Self-mentalization as the third principle. It is
required by every adult in the caregiving system
responsible for the child. It is the ability to reflect
on one’s own mental and emotional processes.
The aim is to develop the capacity to identify and
recognize what happens internally when one is in
front of a child and he/she is reacting to a stressful situation (Fonagy et al. 2002). What it may
trigger within oneself, and the need to understand
this interactional process without acting on the
triggered impulses. The development of this ability enables the adult to differentiate and separate
with greater clarity one’s emotional states from
the child. Several studies have shown that when
this ability is taught to caregivers, their impact on the development of socio-emotional abilities
increases (Denham and Burton 2004).
Regulation is the fourth capacity. This can be
down-regulation (in case of children that are
overwhelmed with stress), or up-regulation (in
case of children that are highly inhibited and
need to express their emotional states) (Gross
2015; Thompson 2015). The goal is to apply
strategies that: (a) decrease the level of stress in
the child; (b) help the child to develop skills for
understanding and regulating emotional expression in ways that promote socio-emotional learning, (c) provide a message of safe haven.
The first three abilities (attention, mentalization, and self-mentalization) are the “mental
training” needed before adults start to carry out a
meaningful and lasting regulation behavior. This
intervention strategy must be more than a simple
application of a behavioral technique or general
advice on child rearing since attention/mentalization/self-mentalization inevitably enables a visualization of the child’s individual needs and
mental and emotional processes.
Implementation of the AMAR
Program Through Chile
The “experts” do not carry out a direct intervention with the caregiving system and the infants
during the implementation of the programs;
instead they train professionals and nonprofessionals (psychologists, educators, social
workers, caregivers, parents) so that change can
be generated by the people who interact daily
with the children. It promotes empowerment of
less expert people who, from the child’s point of
view, have a higher value in terms of survival and
availability (be it in the home, nursery school or
kindergarten, an institutionalization center, a foster family, etc.). With times these strategies will
become an integral part of a culture of respectful
care. The intervention can be adapted and integrated to the culture of each context or institution
(for a review, see Lecannelier 2019).
Given evidence that continuity and constancy
are vital to the successful implementation of
interventions, especially in high-risk populations, (Berlin et al. 2008; Greenberg 2005), the AMAR
interventions have a duration of 4–8 months. This
continuity and constancy is maintained throughout the training and supervision sessions on-site
and off-site. There is ample flexibility around the
number of sessions per program, depending on
the context where the implementation takes
place, economic variables, availability of caregivers’ time, characteristics of the group under
intervention and other factors specific to the reality of each location.
We use videos to show the various situations
so that implementers can learn in an experiential
way the contents of the program. These include
patterns of attachment, mother–baby interactions, stressful situations in infants, and different
way to regulate stress.
AMAR-Caregivers Program
(AMAR-C)
This strategy was originally intended as an intervention for institutionalized babies in orphanages, as in Chile, like in many Latin American
countries foster care was rarely used
(0–24 months) (Lecannelier and Hoffmann
2007). There is ample evidence about the negative effects of early institutionalization (Maclean
2003; Dozier and Rutter 2008; van Ijzendoorn
et al. 2011; Bakermans-Kranenburg et al. 2011;
McCall et al. 2008; Zeanah et al. 2005), in Chile,
the institutionalization of infants at an early age
is a public policy that has been applied massively.
As a first step of intervention in these settings, a
manual was elaborated for the caregivers to
develop skills and encourage vocalization, eye
contact, and physical contact (massage technique, for example), and the ability to identify
difficulties in attachment and temperament
(Lecannelier and Hoffmann 2007; Lecannelier
et al. 2014c). A second version was subsequently
implemented in highly vulnerable nursery
schools in the city of Santiago, Chile (Lecannelier
and Jorquera 2010).
A third version of the manual was funded by
the Chilean government and disseminated at a
national level in two different contexts (Lecannelier et al. 2014b): (a) incarcerated mothers living with their children (during their first
year of life) in all prisons in Chile; (b) institutionalized infants (0–24 months) with difficulties in
nutrition and development.
Implementation Process
- The duration of the intervention is variable. The number of sessions can vary from 12 to 23 sessions once a week.
- Intervention procedures. The implementation of AMAR-C is carried out in the daily context of the infants’ lives. (1) Training facilitators: for the professionals that will carry out the direct intervention with child caregivers who interact daily with the infants (mothers, professionals from nursery school o alternative caregivers). These professionals are called “facilitators,” and are generally psychologists, social workers, or educators with specialization in the infant development and intervention. (2) Process of raising awareness: to generate consciousness of the relevance of the intervention to achieve better commitment, motivation, and adherence to the intervention. Facilitators coordinate meetings with caregivers; (3) Implementation stage: consists of weekly sessions carried out by the facilitators for the adults in charge of the children. In each session, the Attention-Mentalization-SelfMentalization-Regulation skills are learned and practiced. A team of “experts” supervises the facilitators every 2 weeks. A pre-post assessment process includes the use of instruments to measure variables of the adults in charge of the infants (level of stress when caregiving, psychiatric symptoms, and beliefs on child rearing and infant development). Also we look at variables in the infants (general development and socio-emotional development). Evaluation of the attachment and caregiving system (security and attachment patterns and disruptive maternal communication), and of the general caregiving context (resources, caregiving routines carried out by the personnel, language, activities, interactions, and so on); (4) Technical transference process: a strategy was implemented to train two to four professionals to be trainers and ensure the continuity of the program and its dissemination to other locations; (5) recommendations for public policies.
Main Intervention Strategies
Attention
Develop attention to non-verbal processes related
to attachment between the infant and caregiver
(vocalization, eye contact, emotional contact,
proximity, affective holding, affection, proximity
seeking, and need to be calmed down).
Develop attention to disorganized behaviors
in attachment (based on the ADS-III scale).
Develop attention to temperamental processes
in the infant or style of temperament.
Mentalization
Develop the capacity to mentalize using the
mentalization guide (worksheet).
Self-Mentalization
Develop the capacity to identify emotional processes related to the bond with the infant by observing videos and carrying out practical exercises.
Develop self-care habits for the adults when
caregiving.
Regulation
Develop the use of massage techniques for the
children
Develop the use of strategies to calm crying.
Develop the use of interactive play.
Develop the use of stress-regulating strategies
(Time-In and Emotional Education).
Impact of the Intervention
The empirical information showed: (1) a positive
impact on infants and caregivers. Improvements
in the levels of social orientation, emotional reactivity, activity, and orientation to object in the
institutionalized children. The insecure patterns
of attachment had a development significantly
similar to the secure styles, after the intervention
(Lecannelier et al. 2014a, b, c; Lecannelier 2019).
The nationwide implementation in prisons and
early institutionalization centers did not allow for
a control group or randomized selection due to
ethical regulations at government level. However,
improvements in pre- and post-intervention were
found in Disruptive Maternal Communication
and quality of the general caregiving environment (Lecannelier et al, 2007);
Impact on public policies. Our program promoted to develop evidence on a national level
about the status of infants in early institutionalization. Also, progressive change toward early deinstitutionalization in favor of foster care. Third,
an increased awareness of the improvements and
changes in regulations on cohabiting in incarcerated mothers who live with their babies. In Chile,
as in many other countries, mothers can have
their young child while being imprisoned.
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