1. Attachment, a Neurodevelopmental Perspective  Dr Bruce Chenoweth  Consultant Psychiatrist  Senior Staff Specialist, D.A.S. Division. of Women and Children’s Health, St. George Hospital  Conjoint Senior Lecturer, School of Psychiatry, U.N.S.W.

2. Psychiatry—Then and Now!

3. Brain Stuff and Attachment  Walking upright needed bigger prefrontal cortex  Sophisticated ability then possible to focus, plan, control actions, reflect and anticipate, and manage social relations.  Babies needed to be born prematurely and nurtured outside the womb

4. Neurobiology of secure attachments  When a baby is born-------!  Brain development before age of 1 yr is much more extensive than realized  Brain development is much more vulnerable than previously suspected  Neural genesis and apoptosis  Empathic attunement directly influences the maturation of regulatory mechanisms  Stress = asynchrony which is reflected permanently and architecturally

5. Dyadic interaction and brain development  From outset, reciprocal stimulation occurs  Mother is an external CNS regulator of emotion and hence development of the infant PFC  Facial expressions, gaze, touch, body movements and vocalizations generate a symbiotic state  Conversely, lack of +ve interaction causes withdrawal and failure to develop affect self- regulation and to co-regulate social interactions.

6. Physiology of regulation  New neural pathways permit subtle sensory discrimination  Enhanced signaling systems enables the child to construct patterns and take on meaning  This leads to less stress-induced autonomic arousal [which can damage irreparably the formation of sophisticated regulatory pathways]  The full expression of emotional dysregulation may not be apparent until teenage years

7. Not just unhappy kids!  Maternal absence in the first year of life is negatively linked to physiological regulation  Symbiotic “Mind-reading” is only achieved through countless hours of contact. Not innate.  Neural deficits are apparent in children not exposed to good and consistent empathic attunement.  Stress levels are measurable

8. Neural Structures 1  Brain overview

9. Neural Structures 2  Old brain

10. Biochemistry of attachment failure  Chronic stress--<corticotrophin releasing factor and loss of diurnal variation in cortisol level.  High concentration of cortisol receptors in parts of brain responsible for arousal and ability to learn  Rapid increase, adrenalin, nor adrenalin, dopamine  Hyper metabolism in some parts of brain  High thyroid activity-active in brain differentiation and regulation

11. Biochemistry of Good Empathic Attunement  Low stress, low cortisol and low proinflammatory cytokines  High oxytocin leading to down-regulation of primitive fight or flight responses  Hippocampal generation and regeneration after stress.  Improved cortical activity improving executive functioning and affect regulation

12. Attachment Switch—ON!

13. Oxytocin and Fight/Flight Response

14. Impact of Disruption of Bonding on Infant R. Brain Development  Time of most rapid R. brain growth spurt  Neuronal overproduction vs. apoptosis  Semi-permanent arrest of development  Stressful growth inhibitors: excito-toxicity pruning of R. brain cortical circuits  Regulatory failure of emotional homeostasis and attachment  Up-regulation of primitive survival pathways  Vestigial switch-gear, readily triggers emotional dysregulation

15. Yiddisher Mommas!  Before  After

16. Critical role of the Caregiver in the first three months  Continuity of interaction crucial  Caregiver imparts ability to self-sooth  Baby differentiates global states-calmness. Distress and pleasure  Physical sensation and the emotional are bound together-motor responses move from reflexive to volitional mediated by affect.

17. Two to five months  With warm nurturing, investment in and from caregivers increases—differentiation from other adults  Gaze, listening and movement become synchronized  Patterns discerned in caregivers voices  Discrimination occurs between joy, indifference and annoyance  Emotional significance of facial expression and vocalization

18. Infant Development  Baby at 3 months

19. Four to ten months  Purposeful 2-way interaction  Constant carers need to read and respond to emotional signals and challenge to reciprocate  Signaling through facial gestures, gestures, vocalization—broad range of emotions and sensations  By eight months, integrated sequencing of responses and adoption of social patterns

20. Infant Development  Baby at 6 months

21. Infant Development  Baby at 9 months

22. Nine to eighteen months  Continuous flow of to-and fro communication  Complex interactions  Language acquisition

23. Science into Action  Immediate contact following birth  Biological parents preferred over extended family or other care givers  Empathic attunement with baby the critical factor  This requires extended time together with baby  The younger the baby, the more essential is continuity of empathic attunement  Transitions between environments can be stressful for young babies

24. Special Needs Children  Attachments difficult  Reciprocity limited  Dysmorphia  Additional demands  Relationship stress  Maternal guilt/depression  Challenging behaviour

25. Autistic Children  Difficulty with communication, socialization, lack of awareness of others, inability to play, or to copy, and will not seek comfort.  Marked abnormal nonverbal communication  Lack of imaginal world  Abnormal speech, no reciprocal responses  Restricted and stereotyped interests  Extreme distress on transitions

26. Family Court Issues  “Marriage on Rocks” common  Changes very difficult  Consistency essential, transitions difficult  Independent Legal Advisors sometimes don’t understand  Need to work outside established shared-care precedents

27. Take-home message  The brain is plastic—whatever you put in changes the architecture  There are critical times in the developmental trajectory for the establishment of stable patterns which are enduring  The first 18 months are critical times for the genesis of emotional and cognitive regulation  Empathic attunement is critical for this to happen