我们在第四部分描述了婴儿和照顾因素促成的依恋关系。在此第五部分里，Goldberg博士讨论了在逆境条件下依恋的发展。
婴儿的生存和幸福依赖于照顾者。幸运的是，婴儿往往会寻求照顾者的照顾，而照顾者通常也会提供此类照顾。但是，婴儿的寻求照顾的行为，以及父母提供照顾的行为有时候会受到损害、不予理会或压制。当这种情况发生时，依恋关系就可能会受到影响。
逆境有多种形式，可能源于婴儿、照顾者或关系之外的环境。大多数情况下，逆境与诸多相互作用的因素有关。
5.1 早产
由于医疗或生物条件的原因，一些婴儿向照顾者寻求照顾的能力受到了限制。早产儿就是一个例子。与足月婴儿相比，早产儿的警觉和反应能力较差。像微笑、依附、伸手和跟随这些用来实现和保持与照顾者接触的行为的发展变得缓慢。与足月婴儿相比，早产儿住院时间更长，与看护者在一起的时间相对较少。
依恋学者对早产儿进行了研究，以了解这些挑战是否会对婴儿与照顾者的关系产生不利影响。他们发现，尽管足月前婴儿的存在一定的局限性，但大多数婴儿在12至18个月大时仍能安全依附。一般来说，如果没有其他不利因素，早产儿的照顾者能够补偿他们的孩子依恋沟通行为方面的困难。
5.2 虐待婴儿
照顾者能够弥补婴儿的缺陷，但对于大多数遭受到忽视或虐待的婴儿来说，情况并非如此。严重的虐待会危及婴儿的依恋安全。虐待（Maltreatment）不仅包括了虐待（abusive），也包括疏忽（neglectful）。
在虐待情况下，虽然照顾者提供了照顾，但伴随着过度的愤怒、无情或敌意。忽视包括缺乏正常和必要的照顾。这两种形式的虐待经常同时出现。大多数受到虐待的婴儿都有不安全的依恋，许多表现出无组织的依恋模式。无组织的依恋模式要么是缺乏有组织的行为模式，要么是现有的策略反复崩溃。当遭受到压力时，在照顾者在场的情况下，处于无组织依恋关系中的婴儿会显得迷失了方向，表现出不寻常的行为，如转头接近照顾者、恍惚般的僵硬或奇怪的姿势。这些行为被看做是对照顾者感到恐惧或困惑的证据。通常认为无组织是一种极端的不安全感。
遭受虐待并被归类为无组织的婴儿往往会保持这种状态，而被评为安全依恋的婴儿在整个发育过程中往往无法保持其安全状态。
5.3 照顾者抑郁症
还有其他一些情况使照顾者无法为其婴儿提供足够的照顾。母亲的抑郁会限制母亲的情绪可用性，从而干扰正常的照顾。婴儿认为抑郁的母亲是无法接近的、反应迟钝的。有证据表明，母亲的严重和/或慢性抑郁症增加了婴儿与抑郁照顾者者产生不安全依恋的可能性。
5.4 社会逆境
研究社会逆境对依恋的影响存在一个困难，即，不同类型的逆境往往同时发生。例如，极端贫困往往与营养不良、医疗保健差和住房不足有关。这些情况反过来会对照顾者照顾儿童的能力产生不利影响。
研究表明，与在低社会风险环境中成长的儿童相比，在较高的社会风险环境中成长的儿童更缺乏安全感和稳定性。但社会不利条件并不会不可避免地导致不安全的依恋。那些在接受充分照顾的同时又成长成为社会弱势群体的儿童，其安全依恋程度高于照顾不足的社会弱势群体儿童。照顾者的行为可以改善其他的有害环境的影响。
5.5 从早期剥夺或照顾不足中恢复
我们知道某些条件会导致不安全的依恋。一旦婴儿暴露在不利环境中，可以采取任何措施确保他们发展出更安全的依恋吗？在考虑干预问题之前，先看看自然发生的“实验”案例，这些实验中涉及的婴儿，脱离了不利条件并置于更有利环境中。
5.5.1 孤儿院照顾
早期的人们认为，机构养育的婴儿会表现出异常的社会行为，无法建立亲密关系，并且往往会无差别的显示出友好行为。即使是接受了良好的身体照顾和充分的认知刺激的婴儿也会表现出这种不寻常的行为模式。
最近的一些研究着眼于从极度剥夺的孤儿院环境中脱离出来的儿童的康复状况。总的来说，这些研究支持早期研究的发现。虽然领养的儿童在发展和行为方面取得了巨大的进步，但许多儿童发展出了有问题的依恋。
5.5.2 寄养
寄养家庭中的婴儿已被排除在照料不足的环境中。
不到一岁就在寄养家庭接受照顾的婴儿通常会与新的主要照顾者建立新的依恋关系，这取决于这些新的依恋形象（即，养父母家庭的照顾者）在他们情绪不安、身体受伤或生病时对他们的反应。
但对于12个月大后接受照顾的婴儿来说，可能需要长达两个月的时间才能形成稳定的依恋关系。与早期就接受了照料的儿童相比，这些儿童发展出不安全依恋的情况更多。
研究人员认为，受到不充分照顾的婴儿会发展出一些照顾者的行为有关的的模式，旨在保护他们免受虐待。这些行为虽然在出现时具有适应性，但会干扰正常和健康依恋行为的发展。因此，在虐待条件下长大的婴儿需要的，可能不仅仅是良好的照顾来建立安全的依恋关系。他们可能还需要治疗干预，他们的照顾者需要足够的支持和指导。
这些收养和寄养调查结果提供了一些关于从逆境中恢复的潜力，以及严重和长期不利条件所施加的限制的见解。
5.6 帮助被虐待的幸存者
在逆境中成长的儿童，特别是在遭受虐待的情况下，制定的应对策略与引起照顾者注意和接触的行为背道而驰。
例如，受到虐待的儿童往往高度警惕，常常将模棱两可的刺激解释为威胁。
这些应对策略会干扰积极关系的发展。遭受虐待的儿童往往必须接受教育，使他们能够接受新的、可能是积极的关系和经历。
从本质上说，治疗干预必须帮助受虐儿童克服对人际关系的消极信念。对于经历过极端虐待或忽视的孩子来说，积极的新体验可能会引起焦虑，而不是安慰。受虐待儿童希望所有情况都能证实他们在与虐待照料者的关系中学到了什么。当面对一些与以上期望相反的情况时，即使是积极的，也可能导致不平衡，加剧焦虑。受虐儿童的治疗必须侧重于帮助他们相信——并非所有成年人都会拒绝或虐待他们。
对于年龄较大的儿童治疗而言，促进积极的同伴互动是其中的一个主要组成部分。受虐待的儿童容易重复他们过去的消极关系模式。治疗的目标是鼓励一些新的关系模式，这些模式不同于曾经熟悉的消极模式。
童年时期就遭受过虐待的成年人是治疗师的一个特殊的挑战。许多在儿童时期就遭受过虐待的成年人，他们在面对现在的世界时往往期望自己成为受害者。这些人往往不信任他人，很强烈的抵制改变的发生。一般来说，能够最大限度地减少依恋问题的终身影响的最有效方法，就是预防和早期干预。
5.7 改善婴儿和照顾者的关系
许多依恋驱动的治疗方法侧重于改善婴儿与照顾者的关系。这些疗法已成功应用于高危人群。
一些照顾者及其子女，因贫困、缺乏教育和其他生活压力而负担沉重，他们对一些干预措施反应良好。在这些干预实施之后，一些照料者表现出更大的同理心，更多的与婴儿互动，婴儿表现出更少的回避、抵抗和愤怒。
大多数把干预的重点放在婴儿-照顾者关系的干预措施往往侧重于提高父母对婴儿线索和信号的敏感性。但研究表明，尽管照顾者的敏感性与不同的有组织依恋模式有关，但与无组织依恋无关。此外，无组织的依恋是严重精神病理学和情绪或行为问题最强的预测因子之一。
最近由Diane Benoit及其同事在儿童医院进行的一项试点研究探讨了一项简短的、重点关注照顾者培训干预的有效性。修改后的互动指南不仅旨在提高看护者的敏感性，还特别关那些和无组织依恋有关的照顾者的行为。干预措施包括对照顾者和孩子之间的互动进行录像，然后与训练有素的治疗师进行讨论和反馈。
修改交互指导的初步结果充满了希望。参与干预的照料者的无组织依恋相关行为发生了下降。加拿大各地的许多研究正在对高危家庭、有临床问题的儿童、未成年母亲的儿童以及参与儿童保护服务的家庭测试这种方法的有效性。
其他以依恋为基础的计划也提供了由于生物、医学或心理社会风险而有发育迟缓风险的婴儿的照料者。从一开始，汉密尔顿健康科学和麦克马斯特大学婴儿家长计划的艾莉森·尼科尔斯（Alison Niccols）就设计了一个为期8周的家长培训课程，旨在改善照顾者与孩子之间的互动，培养依恋安全感。初步研究表明，该计划成功地实现了改善婴儿照顾者关系的目标。
多年来，已经开发了许多基于依恋的干预措施，其中许多仍在开发中，越来越多的干预措施正在接受越来越严格的科学测试。未来有希望发展经验证的干预措施，以提高照顾者的敏感性，并降低发展不安全和/或无组织依恋的风险。图片
在我们的第六部分也是这一系列的最后一部分中，我们将讨论 依恋理论的社会影响。
Diane Benoit, MD, FRCPC
Sheri Madigan, PhD, C.Psych (监督实践)
5/13/2010
Benoit, D. Modified Interaction Guidance. Newsletter of the Infant Mental Health Promotion Project. Winter 2001-2002;32:61-65.
Goldberg S. Attachment and Development. Hillsdale, NJ: The Analytic Press; 2000.
Goldberg S, Muir R, Kerr J, eds. Attachment Theory. Hillsdale, NJ:The Analytic Press;1995.
Infants depend on caregivers for their survival and well-being. Fortunately, infants are predisposed to solicit care from caregivers and caregivers are predisposed to provide such care. But sometimes an infant's care-seeking behaviours or a parent’s caregiving behaviours are impaired, overridden or suppressed. When this happens, the attachment relationship can suffer.
Adversity comes in many forms and can originate in the infant, the caregiver or from circumstances outside of the relationship. Most often, adversity involves multiple interacting factors.
Premature birth
Some infants are limited in their capacity to solicit care from caregivers due to medical or biological conditions. Premature babies are one example. Pre-term infants are less alert and less responsive than full-term babies. A number of behaviours used to achieve and maintain contact with caregivers such as smiling, clinging, reaching and following are slow to develop. Premature infants are also more likely to spend extended time in hospital and have limited time with caregivers compared to full-term babies.
Attachment researchers have studied premature infants to see whether these challenges adversely affect the infant-caregiver relationship. They have found that despite pre-term infants’ limitations, the majority are securely attached by 12 to 18 months of age. In general, if other adversities do not arise, caregivers of premature babies are able to compensate for their children’s difficulties in communicating attachment behaviours.
Infant maltreatment
Caregivers are able to compensate for infant limitations but the same cannot be said for most babies facing neglect or abuse. An infant's attachment security is seriously jeopardized by maltreatment. Maltreatment can be either abusive or neglectful. In cases of abuse, care is provided but is accompanied by excessive anger, harshness or hostility. Neglect involves a lack of normal and necessary care. The two forms of maltreatment often co-exist.
The majority of infants who are maltreated are insecurely attached and many display disorganized attachment patterns. Recall from the first feature in this series that a disorganized attachment pattern involves either a lack of an organized behaviour pattern or existing strategies that repeatedly break down. When stressed, in the presence of their caregiver, infants in disorganized attachment relationships appear disoriented, displaying unusual behaviours such as approaching the caregiver with their head averted, trance-like freezing or strange postures. These behaviours have been interpreted as evidence of fear or confusion with respect to the caregiver. Disorganization is considered an extreme form of insecurity.
Infants who have suffered from maltreated and are classified as disorganized tend to remain so and those who are rated as secure often do not maintain their secure status throughout development.
Caregiver depression
There are other circumstances which leave caregivers unable to provide adequate care for their infants. Maternal depression can interfere with normal caregiving by limiting a mother’s emotional availability. To the infant, a depressed caregiver is perceived as inaccessible and unresponsive. There is evidence that severe and chronic maternal depression increases the likelihood that an infant will develop insecure attachment with that depressed caregiver.
Social disadvantage
One difficulty in studying the impact of social adversity on attachment is that different types of disadvantage often occur together. For example, extreme poverty is often associated with poor nutrition, poor medical care and inadequate housing. These conditions in turn adversely affect a caregiver's ability to care for children.
Research shows that children growing up under conditions of high social risk have less secure and less stable attachments than children growing up in low social risk environments. But conditions of social disadvantage do not inevitably lead to insecure attachment. Children growing up socially disadvantaged while receiving adequate care show higher levels of secure attachment than socially disadvantaged children with inadequate care. Caregiver behaviour can ameliorate the effects of other harmful circumstances.
Recovery from early deprivation or inadequate care
We know that certain conditions contribute to insecure attachment. Once an infant has been exposed to adverse circumstances, can anything be done to ensure the development of more secure attachment? Before considering the issue of intervention, it is helpful to look at the case of naturally occurring “experiments” involving infants who are removed from adverse conditions and placed in more advantageous environments.
Orphanage care
Early accounts of institution-reared infants describe babies who display unusual social behaviours, are unable to form close relationships and are often indiscriminately friendly. Even infants who received excellent physical care and adequate cognitive stimulation display these kinds of unusual behaviour patterns. A number of more recent studies have looked at the recovery of adopted children taken from the extremely deprived conditions of orphanages. In general, these studies support the findings of earlier research. Although the adopted children made substantial developmental and behavioural gains, many developed problematic attachments.
Foster care
Infants in foster homes have been removed from conditions of inadequate care. Infants who are put into care before 12 months of age usually develop a new attachment relationship with their new primary caregiver, based on how this new attachment figure reacts to them when they are emotionally upset, physically hurt or ill. But for babies placed into care after 12 months of age it can take up to two months for stable attachment relationships to emerge. These children also develop more insecure attachments than children who are placed into care earlier.
Researchers have suggested that babies who receive inadequate care develop patterns of relating to caregivers that are designed to protect them from abuse. These behaviours, although adaptive at the time that they emerge, interfere with the development of normal and healthy attachment behaviours. For this reason, babies raised under conditions of maltreatment may require more than good care to establish secure attachments. They may need therapeutic intervention and their caregivers need adequate support and guidance.
These adoption and foster care findings provide some insight into the potential for recovery from adversity as well as the limitations imposed by severe and prolonged disadvantage.
Help for victims of maltreatment
Children who grow up under adversity, particularly if they are maltreated, develop coping strategies that are counter to behaviours that solicit caregiver attention and contact. For example, children who have been maltreated tend to be hyper-vigilant and often interpret ambiguous stimuli as threatening. These coping strategies interfere with the development of positive relationships. Children experiencing maltreatment often must be taught to be open to new and potentially positive relationships and experiences.
Essentially, therapeutic interventions must help the abused child overcome negative beliefs about relationships. For a child who has experienced extreme abuse or neglect, positive new experiences can be anxiety provoking rather than comforting. Maltreated children expect all situations to confirm what they have learned in their relationships with maltreating caregivers. When faced with situations that are contrary to these expectations, even though positive, disequilibrium may result and anxiety escalates. Treatment for maltreated children must focus on helping them believe that not all adults will reject or abuse them.
Facilitating positive peer interaction is a major component of therapy with older children. Maltreated children are prone to repeat negative relationship patterns from their past. A goal of therapy is to encourage relationships that diverge from familiar negative patterns.
Adults who suffered childhood abuse present a special challenge to therapists. Many adults who were subjected to maltreatment as children face the world expecting to be victimized. These individuals tend to be mistrusting of others and their resistance to change is often powerful. In general, prevention and early intervention are the most effective methods for minimizing the life-long effects of attachment-based problems.
Improving the infant-caregiver relationship
A number of attachment-driven therapeutic approaches focus on improving the infant-caregiver relationship. Therapy has been used successfully with high-risk groups. Some caregivers and their offspring burdened by poverty, lack of education and other life stressors, have responded well to some interventions. Some caregivers show greater empathy and interaction with their infants, following these interventions and infants show less avoidance, resistance, and anger.
Most interventions that focus on infant-caregiver relationships focus on improving parental sensitivity to baby's cues and signals. But research has shown that while caregiver sensitivity is associated with the different patterns of organized attachment, it is not associated with disorganized attachment. Further, disorganized attachment is one of the strongest predictors of serious psychopathology and emotional or behavioural problems.
A recent pilot study conducted by Diane Benoit and colleagues at The Hospital for Sick Children explored the efficacy of a brief, focused, caregiver-training intervention. Modified Interaction Guidance was designed to not only improve caregiver sensitivity but also to focus specifically on caregiver behaviours associated with disorganized attachment. The intervention involves videotaped interactions between caregiver and child followed by discussion and feedback with a trained therapist.
Preliminary findings with Modified Interaction Guidance are promising. Caregiver behaviours associated with disorganized attachment declined after participation in the intervention. A number of studies across Canada are testing the effectiveness of this approach with high-risk families, children with clinical problems, and children of adolescent mothers, and families involved with child protection services.
Other attachment-based programs have been offered to caregivers of infants at risk of developmental delay due to biological, medical, or psychosocial risk. Right from the Start, an 8-week parenting training course developed by Alison Niccols of the Infant Parent Program at Hamilton Health Sciences and McMaster University, was designed to improve caregiver-child interaction to foster attachment security. Preliminary research suggests that the program is successful in achieving its goal of improving the infant-caregiver relationship.
Numerous attachment-based interventions have been developed over the years, many are still under development, and a growing number are being tested with increasing scientific rigor. The future holds promise for the development of proven interventions to improve caregiver sensitivity and reduce the risk of developing insecure and/or disorganized attachment.
In Attachment Part Six: Implications of attachment theory: past, present, and future we will explore the societal implications of attachment theory.
