1. The role of attachment and resiliency in the intergenerational transmission of depression: results from the Cambridge Longitudinal Study Lynne Murray Winnicott Research Unit, University of Reading with Adriane Arteche, Peter Cooper, Sarah Halligan, Pasco Fearon and Matt Woolgar Funding: MRC, UK; Tedworth Trust; Winnicott Trust

2. Intergenerational transmission of depression Consistent reports of offspring of parents with depression being at substantially increased risk for depression themselves: - e.g., Leib et al., 2002 Lewinsohn et al., 2005 Weissman et al., 2006 Timko et al., 2008 However, little prospective longitudinal data concerning development of disorder through childhood.

3. How might insecure attachment be involved in intergenerational transmission of psychopathology? Dear Nick, it was very helpful to meet last

4. Bowlby’s theory of attachment Concerns propensity to make close emotional bonds Need for protection a prominent feature early in development Security promotes independence

5. Attachment quality Secure: can rely on parent for support when distressed Insecure avoidant: minimize expression of distress, avoid close contact Insecure ambivalent: maximize expression of distress at separation, mixed with anger Disorganised: no clear strategy, confused, irrelevant, freezing

6. Parenting and attachment Secure: available, responsive, sensitive Insecure avoidant: rejection Insecure ambivalent: inconsistent Disorganised: frightening behaviour/ maltreatment

7. Bowlby’s view of mental health implications Avoidant –Deny needs –Attempt to live without others’ love and support –Sense of self as not worthy of love –Low expectations of others Ambivalent –Pervasive anxiety, especially re. separation/abandonment –Limited exploration of world –Coping capacities not developed

8. Characteristics of attachment Repeated patterns of interaction become internalised as IWM’s Self-perpetuating Relatively flexible early on, but become more fixed over time Early experience special, as provides ‘setting point’

9. Evidence to date: Minnesota longitudinal study of mental health outcomes Avoidant/disorganized – predicts more global pathology (Sroufe, 2005) Ambivalent – predicts anxiety diagnoses (Warren, 1997) Avoidant – predicts externalizing, early onset antisocial (Aquilar, 2000; Sroufe, 2005) Disorganised – predicts dissociation (Carlson, 1998) other disorders (Liotti, 2004; 2008) NB not strong effects, adversity adds

10. Role of attachment insecurity in transmission of depression Depressed mothers’ interactions: Generally insensitive – - Withdrawn, unresponsive - Intrusive, hostile

11. Effects of depression on infant attachment Systematic associations shown between PND and insecure attachment Meta analyses- Martins and Gaffan, 2000 Atkinson et al., 2000 Plus Campbell et al., 2004 (NICHD sample)

12. Bowlby’s view of mental health implications of attachment for ego resiliency Avoidant –Deny needs –Attempt to live without others’ love and support –Sense of self as not worthy of love –Low expectations of others Ambivalent –Pervasive anxiety, especially re. separation/abandonment –Limited exploration of world –Coping capacities not developed

13. Ego resiliency Thus, the insecure child may:- lack capacity to cope with threat have rigid, or limited coping strategies be overwhelmed with sense of loss/anxiety have low self-worth (Erikson, 1985)

14. Predicted pathway PND  insecurity  low ego resiliency  depression

15. Cambridge longitudinal study Sample Low risk mothers cohabiting/married Infants healthy Community sample screened at 6 weeks 58 depressed, 42 controls recruited Assessed so far to 16 years

16. video clips of interactions

17. Key child assessments beyond postnatal period 18 months- attachment 5 years- ego resiliency 8 years- ego resiliency 16 years- psychiatric outcome

18. Other potentially important influences Continuing quality of mother-child relationship Chronicity of maternal depression Marital conflict

19. Occurrence of depression assessed 8-16 years At each time point, a standardised interview (the K- SADS) was used, and administered by a researcher unaware of maternal diagnosis, to mother and child independently At 8 years current state was assessed At 13 and 16 years current and previous mental state to previous assessment was assessed Diagnoses assigned by senior clinical team, according to best estimate, combining maternal and child report.

20. Cambridge Longitudinal study: Depression in the children 8-13 years ** * Depression begins to emerge at 11-yrs: higher rates of depressive disorder present in the PND group by 13-yrs

21. Cambridge Longitudinal study: Depression in the children 13 to 16-years ** *** Rates of disorder continue to increase, particularly because of the emergence of depression in the PND group

22. Cambridge Longitudinal PND study: 16 years life-time depression - full sample

23. PND and 16 yr life-time depression, including child sex

24. Developmental trajectory to depression The roles of infant attachment and ego resiliency, and the subsequent mother-child relationship

25. Insecure infant attachment: Effects of PND

26. Infant attachment: Relation to 16 years lifetime depression

27. Ego resiliency at 5 and 8 years: Effects of PND and attachment, and relation to 16 yr life-time depression The Snap card game (Murray et al., 2001) Child at home with friend Competitive card game Rigged by experimenter to provide losing and winning deals (both children win at end!) Rate child’s distress and anxiety in the face of the mild threat of loss

28. video clips of card game

29. Ego resiliency at 5 and at 8 years: Effects of PND

30. Ego resiliency at 5 and at 8 years: Effects of attachment

31. Ego resiliency at 5 and at 8 years: Relation to 16 yr life-time depression

32. Maternal sensitivity and emotional support at 5 and 8 years Maternal sensitivity at 5 years- assessed during ‘snack’ in research unit (warmth, appropriate responsiveness) (Murray et al., 1999) Maternal emotional support at 8 years- assessed during child homework session (available, positively responsive) (Murray et al., 2006)

33. Maternal insensitivity at 5 years: Effects of PND PND effects: F(1, 84)=2.91, p<.10 sex effects: ns PND*sex: ns +

34. Maternal insensitivity at 5 years: Effects of attachment attachment effects: F(1, 84)=2.90, p<.10 sex effects: ns attachment*sex: ns +

35. Maternal insensitivity at 5 years: Relation to adolescent depression *

36. No effects of 8 yr emotional support

37. Pathway so far: PND, attachment, 5 and 8 yr resiliency, and maternal insensitivity at 5 yrs PND Infant Attach ER 8yrs 5yrs insensitivity 16y lifetime depression p=.05 ER 5yrs p=.09 p=.05 p=.006 p=.06 p=.05 p<.001 p=.004

38. The role of chronic difficulties Maternal depression –Assessed at each time point, with month-by-month recording of offsets and onsets of disorder to give chronicity Marital conflict –Assessed at each time point by interview/questionnaire

39. Chronicity of maternal depression Women in the PND group experienced further depression outside the postnatal period

40. Marital conflict: Relation to PND **

41. What about continuing maternal depression & marital conflict? Effects of these difficulties following each stage of child development attachment 18m Depression <16yrs chronicity mat. depression p<.01 marital conflict at 18m, 5, 8 & 13y p=.04

42. low ego resilience 5y Depression <16yrs MODEL 1 attach 18m chronicity mat. depression (5y-onset) p<.05 marital conflict 5+8 +13 p=.06 MODEL 2 attach 18m low ego resilience 5y chronicity mat. depression (8y-onset) ns Depression <16yrs low ego resilience 8y marital conflict at 8+ 13y ns

43. What about mother-child interactions? attachment 18m Depression <16yrs maternal insensitivity at 5yrs p<.10 maternal emotional support at 8yrs ns low ego resilience 5y MODEL 1 maternal emotional support at 8yrs ns Depression <16yrs attachment 18m maternal insensitivity at 5yrs ns

44. Summary Main study finding: Child depression up to 16 yrs is predicted by PND, insecure attachment, and poor resiliency, especially at 8 yrs.

45. Supplementary findings: a) the role of subsequent maternal interactions Once infant attachment is taken into account, the contribution of maternal insensitivity at 5 yrs is only marginal. That of 8yr maternal support is not significant. Once infant attachment and 5yr resiliency are taken into account, the mother’s insensitivity at 5 yrs does not contribute further to risk of depression (and 8yr support remains non-significant)

46. Supplementary findings: b) the role of further maternal depression and conflict Once infant attachment is taken into account, there is still an additional effect of continuing maternal depression and marital conflict Once attachment and 5yr resiliency are taken into account, the effect of continuing maternal depression is still significant, but the role of subsequent marital conflict is reduced Once attachment and both 5 and 8yr resiliency are taken into account, neither further maternal depression, nor marital conflict add to the risk of child depression

47. Overall conclusion PND and its effects on child development through the first 8 years predict the occurrence of child depression up to 16 years. Negative experience subsequent to the first 8 years does not add further to the child’s risk of depressive disorder