Dysfunctional attachment and psychopathological outcomes in childhood and adulthood

The paternity of the studies on the “attachment theory”, about the maternal bond and the consequences of the deprivation of maternal care, is by John Bowlby, who modifi ed the current conception according to which the maternal bond was based on hunger and nutrition: hunger was considered a primary drive that regulates the relationship of “dependence” between mother and child. Addiction has been considered as a link that must be progressively dissolved in order not to acquire an exclusively regressive character. “Dependency” thus took on a pejorative meaning [1].


Defi nition, characteristics and contextual analysis of the attachment theory and its evolution
The paternity of the studies on the "attachment theory", about the maternal bond and the consequences of the deprivation of maternal care, is by John Bowlby, who modifi ed the current conception according to which the maternal bond was based on hunger and nutrition: hunger was considered a primary drive that regulates the relationship of "dependence" between mother and child. Addiction has been considered as a link that must be progressively dissolved in order not to acquire an exclusively regressive character. "Dependency" thus took on a pejorative meaning [1].
Thanks to the observation of the behaviours of children separated from their parents, he postulated the existence of an innate and autonomous tendency in man to seek the protective closeness of a well-known fi gure every time one experiences situations of danger, stress, pain and he called it "attachment" [1]. The attachment bond between parents and children was then studied and also experimented on small primates by the Harlow spouses (Harry Frederick and Clara Mears Harlow) between 1958 and 1965. The Harlows raised macaque cubs depriving them of their mother; the monkeys had only two maternal substitutes: one was a plush of soft cloth and the other of metal; the latter was equipped with a bottle to which the hungry monkeys attached to suck the milk. The spouses, after repeated observations, noticed that the monkeys spent most of the time-bound to the cloth puppet, even if it was devoid of bottles, and they attached themselves to the metallic shape only to suck. After a few weeks, the monkeys became sad and frightened due to lack of physical contact and looks. When the monkeys became adults they behaved like "bad mothers": they showed indifference towards their little ones, they did not breast-feed them, they did not rebel if something happened to the little ones and they came to attack them and refuse them [2].
Bowlby was convinced that it was necessary to distinguish between [1]: a) "attachment", which is an innate disposition that persists, changing only very slowly over time. It is a behaviour that manifests itself in a person who obtains or maintains the proximity of another person considered capable of facing the world adequately. It is more evident in the small ones, but it is active for the whole life, and the operation is based on four groups of behaviours: -the "exploratory system": the caregiver, providing a secure base, allows the child to explore the surrounding environment, creating the ideal adaptation over time; -the "fear system": closely linked to the function of protection and safeguard (fear activates attachment); -the "system of sociability": the child looks for the company when he is safe and relaxed; -the "system of care": series of attentions aimed at defence and protection. b) the "attachment behaviour", which the person puts in place from time to time to obtain, maintain and restore proximity with the fi gure from which he receives protection. In particular, attachment behaviour: -is defi ned as that behaviour aimed at seeking or maintaining proximity towards a particular person who is considered capable of facing the world and providing protection (e.g. smile, crying, formal and/or informal requests to attract attention); -is accentuated in situations of stress and danger, while it is attenuated when comfort and care are received; -is characteristic of early childhood, but maybe within the entire life cycle; -its biological function is comparable to that of protection from predators; -corresponds to a behavioural system, that is to say, an internal psychological organization that includes both behavioural patterns, representation patterns of the self and the attachment fi gure, and behavioural patterns that have biological roots, differentiated from those that regulate sexual behaviour, that of exploration and food; -The conditions that stop the attachment behaviour vary depending on the intensity of its activation. Bowlby observed that if the absence of the mother was fi nal or was usually prolonged beyond the limit of tolerability, the attachment behaviour risked being deactivated: the child, after a certain period of separation from the mother, when it returns: the traffi cking as a stranger; after a while, he clings to her very distressed to be able to lose her and angry. The prolonged absence has deactivated the attachment behaviour control system. Those signals and information that would trigger attachment behaviours aimed at requiring the presence of the mother and her consolation are excluded. This is a defensive exclusion that occurs when the child despairs of the presence of the mother. This defensive exclusion, or avoidance behaviour, becomes operative even with mothers who systematically refuse physical contact with the child or are indifferent, insensitive.
The child, and later the adult, become fearful of being able to attach themselves to someone for fear of suffering a further refusal, a block is created that prevents them from expressing or even from experiencing the natural desire for an intimate, trusting relationship of care and comfort and love: a positive attachment. A subject who has become avoidant will be afraid to enter into a trusting relationship even with the analyst. Notable is the intensity and quality of the emotion that accompanies attachment behaviour, and that depends on the relationship between the people involved. If the relationship is good, there is joy and a sense of security even in the manifestation of the need for attachment and in the search for attention by the signifi cant fi gure: it depends on the behaviour of the parents which corresponds to a pattern of parental behaviour, partly innate and partly learned both during the interaction with the children, both through the observation of the other parents and in relation with their parents. A good interaction is one in which the sensitive mother regulates her behaviour to match it with that of the child. The mother's positive attitudes depend on: a) working in a relaxed environment; b) from being helped and supported practically and emotionally; c) from being in turn, as a child, objects of proper care. The behavioural model of caring starts very early and is infl uenced decisively by parents; women with troubled childhood tend to have fewer interactions with their children; those that have been abused tend to become abusive in their turn. Mothers who have received little care and have had to take care of their parents will tend to expect care and attention from their children, reversing the relationship and creating symbiotic relationships dominated by their attachment anxiety. A positive attitude of parents provides children with a secure base, which encourages them to explore autonomy: providing a secure base of attachment means creating the optimal conditions for a child or adolescent to break away and face the outside world, knowing however always to be able to return to that protected place where they will be gathered and nourished on a physical and emotional level, comforted if they are sad, reassured if they are scared.
During adolescence, attachments can be maintained without actual physical proximity. Adolescents become active in the search for new attachments outside the family and accept responsibilities connected with being an attachment fi gure for new partners.
Based on these theories, Bowlby came to defi ne the "genesis of attachment", identifying fi ve particular phases [3]: 1) I (0-3 months): the "pre-attachment" consists in the implementation of orientation behaviours of space (turning the head) and signalling (smile, crying, letting) with anyone who comes into contact. The child, while recognizing the human fi gure when it appears in his visual fi eld, does not discriminate and does not specifi cally recognize people.
2) II (3-6 months): the "attachment information". The newborn begins to distinguish the fi gures that take care of him from those who are occasional, showing him with increasingly evident and marked behaviours (smile). In 80% of cases, it shows the fear of strangers.
3) III (7-8 months): the "anguish". Not having yet developed the concept of the permanence of the object, the distance from the breeding fi gure causes anguish in the child because he is afraid that the "caregiver" will not return. More and more fi gure is recognized by the child who, in addition to identifying the physical characteristics, becomes aware of his feeling, emotions, feelings. Based on the answers that the parents will give to the child, different types of bonds will be produced later.
Mary Ainsworth, Bowlby's assistant, contributed to the formulation of the attachment theory, elaborating a particular experimental situation: the "strange situation" [4][5], which allowed to evaluate the different attachment behaviour of children in response to separation from the mother. The experiment, divided into eight phases or episodes, each lasting three minutes, had as its protagonist a child subjected to situations that could potentially generate "relational stress": 1 st episode. In a particular room, a parent (caregiver) with his son was allowed in and subsequently left alone.

Attachment styles in childhood and their evolutions in adulthood
Always referring to the "strange situation", the researchers thus created an essential clinical tool, called "Adult Attachment Interview (AAI)" and identifi ed four patterns of infantile attachment, defi ned "attachment styles" [2], then functional for analysis of the possible clinical and psychopathological profi les in the subject's developmental age: "safe", "insecureavoidant", "insecure-ambivalent", "disorganized". This attachment pattern is marked with the letter A because it was the fi rst to be identifi ed, it is called "avoidant", due to its marked behavioural characteristic, which is precisely the activation, which cannot be deduced from the behaviour.
After all, it is hypercontrolled or repressed by the child. At the time of the meeting, these children not only maintain their apparent indifference, but actively tend to avoid physical contact, and sometimes only the contact of glances, with the parent. Children do not protest at the time of separation of the mother (indifferent, continue to play or interact with the extraneous adult), actively avoid the mother at the time of her rapprochement after separation and are inhibited in the game. Mothers are rejecting, angry or even hostile; they have an aversion to physical contact, a rigid and not very expressive mimicry, they are annoyed by requests for comfort and protection, especially when the child shows more actively the need through avoidance behaviour. Since the child fi nds himself angry with his mother, who is not responsive and given that he fears rejection, he will adopt the avoiding defence by detaching the attachment behaviour from any environmental signals and information that usually activate him: he does not live off her mother nor her return as a stimulus to close desire contact with her; it avoids both the search for contact and anger because both have a high probability of evoking rejection. The antecedents of this insensitivity and maternal non-responsiveness can be: -The mother is, in turn, insecure, anxious. He gets angry or avoids answering his son's increasingly anxious requests. Children actively and calmly explore the environment in the presence of their mother; they cry little at the time of separation; they protest loudly at the time of the meeting, immediately resuming their activity. The mothers of these children show sensitivity in responding to the signals the child sends them, providing comfort and protection only when they are required. The child vigorously protests at the time of separation from the attachment fi gure; they continue to look for her during her absence and calmly calm down at the meeting with her. This child appears determined and confi dent in his search for the parent, and also sure of the comfort that he will offer him when he is reunited. This child will have a parent who at the Adult Attachment Interview (AAI) turned out to belong to the "free" category (F), for the characteristic freedom of refl ection, argumentation and remembrance of his childhood; his speech was consistent during the description of attachment experiences, is attentive to the examiner's questions, shows signs of considering his mental state taking into account the mental state of the examiner. Consider the human need for care and protection as adequate and regular.
It will not necessarily tell hilarious episodes; you may tell traumatic episodes. Not necessarily such adults, as infants, had an attachment pattern (B), but what emerges at the time of the AAI is that the mental state related to attachment is safe. From the mental state of the adult, we can predict the attachment pattern of the child and vice versa, this demonstrates the intergenerational transmission, but this transmission may stop and evolves positively due to awareness taking. c) "Type C: Insecure and ambivalent attachment".
Children who have this type of attachment pattern show considerable discomfort at the time of separation from the attachment fi gure, crying angrily or letting go of anger. At the time of the meeting, they fail to be consoled and show resistant behaviour, or they can show passive behaviour. It is called ambivalent (the child seems ambivalent towards the attachment fi gure, desiring its presence but also refusing the comfort that should derive from its embrace) or resistant (for the natural resistance to receive comfort shown at the time of reunion).
The children are very distressed and protesting like the Bs at the time of separation, but they cannot be easily pacifi ed at the time of the meeting, they continue to cry despite the mothers' attempts to console them, they seek their contact but they resist kicking, running away or throwing away the toys that are offered to them, continue to alternate states of anger and moments in which they violently cling to their mother, while their exploration of the environment is inhibited. Mothers appear unpredictable and inconsistent in their willingness to respond to the child's attachment needs and accessibility; they are intrusive and hyper-controlling, limiting the child's tendency to the autonomous exploration of the environment.
The child's proximity and contact requests are often frustrated, and the child's attachment behaviour persists and tends to intensify and mingle with anger. When the mother responds, the child behaves in an ambivalent manner and is diffi cult to appease, cannot rely on the accessibility of the mother, There is a lack of organization of attachment behaviour: when children are reunited with their mother they have confused, and contradictory behaviours, sudden arrests in approaching movements, strange "fi xity" of the gaze and movements that appear stereotyped, or are paralyzed when they are taken into the neck from the mother. The mothers of these children have a caregiving behaviour that is called frightened or scared: they

Internal operating models
The "attachment theory" holds that the child constructs IOMs fi lter the incoming information, the elaboration of the information in the output, triggering selective attention processes, selective perception, selective memory, this in an unconscious way for the individual. This is due to a need for coherence on the part of the individual, who selects information that is congruent with his expectations. Furthermore, this is a system to prevent and defensively exclude information that could make the attachment system reactivate. The individual wants to avoid pain, while it can be excruciating to face one's fear and need to be comforted and not to receive comfort and support from one's attachment fi gure, as happened in childhood. The security of attachment, which promotes inner security and a sense of self, is characterized by the ability to ask for comfort, or by the ability to express the pleasure of not being in a dangerous situation. Individuals with an insecure attachment process information in a prejudicial manner, exclude from processing the information that could trigger the attachment system, because they expect, based on their fi rst experiences, that they cannot be comforted. We can place IOMs in the cognitive-verbal level, the level that connects us with the world through cognition, that is our way of thinking, our ideas, our language, our culture. "Our ability to" refl ect "to turn back to our personal history, create the concept we have of ourselves, strengthen our identity and the roles we have

Psychopathological profi les in childhood and adulthood
In recent years, the studies carried out have investigated psychosocial adaptation and functioning during development about attachment, highlighting the correlation between secure attachment and positive affectivity with excellent problemsolving skills and self-confi dence and a better adaptation, especially in the fi rst years of life [13].
The behavioural and emotional strategies associated with insecure attachment models, on the other hand, constitute a context of minor adaptation to child development, although there is little correlation between insecure attachment and psychopathological outcomes in preschool and school-age, except for samples with high psychosocial risk. In these studies, the psychosocial risk condition, such as extreme poverty, the single parent, the disintegrated family context, factors such as maternal depression, contribute both to create predisposing factors for the development of an insecure attachment and to function as further factors of risk [14].
The results of clinical studies are rather heterogeneous: in the Minnesota Parent-Child Project [15] there is a signifi cant correlation between insecure attachment in childhood and clinical symptoms in school age, including confl icts with peers, the variability of mood, aggressiveness and externalizing symptoms [16]; Lyons-Ruth studies [14,17], report signifi cant data in which maternal depression, associated with an insecure-disorganized attachment, would predispose to hostile behaviours and externalizing disorders in school age, while associated with an insecure-avoidant attachment would result in symptoms internalizing; fi nally, Greenberg's research [18], shows an association between insecure-avoidant or insecure-disorganized attachment and conduct disorders.
In all these studies, a secure attachment would represent an essential protective factor for development. It can be concluded that from a theoretical point of view the strategies of insecure attachment predispose to externalizing disorders (aggressiveness, delinquent behaviour) and internalizing (social withdrawal, anxiety) but research on this does not indicate specifi c outcomes associated with particular types of insecurity.
Concerning adulthood, two broad areas of empirical research are identifi ed, aimed at investigating the relationship between attachment and psychopathological outcomes: that of longitudinal studies that have followed the evolutionary pathway from childhood to adulthood, and that of the studies that have investigated the state of mind related to attachment through tools such as the Adult Attachment Interview or selfreport questionnaires. The fi rst area, given the complexity of the research, is represented by a few studies from which it is possible to deduce a specifi city of the ambivalent attachment for the development of anxiety disorders [19] and disorganized attachment to dissociative symptoms [20]. The correlation found in these studies is supported by a phenotypic similarity of these phenomena and the quality of the experiences of care that are hypothesised are the basis of both the ambivalent attachment and the anxiety disorders (incoherent treatment), as well as the basis of both disorganized attachment than of dissociative symptoms (experiences of abuse). The research carried out through the AAI or self-report questionnaires certainly appears to be more numerous but also more contrasting, however, it is possible to outline a theoretical framework that sees in the minimizing (avoiding-distancing) strategies a predisposition to externalizing disorders and in amplifying (ambivalentworried) a predisposition to internalizing disorders. Research suggests a signifi cant association between anxious attachment and borderline and modest personality disorder with the internalizing forms of anxiety and depression disorders [21].
Unlike insecure-avoidant and insecure-ambivalent forms of attachment, disorganized attachment appears to be associated more frequently with specifi c forms of psychopathology.
Longitudinal research and studies that have investigated the mental state related to attachment in childhood seem to agree with the hypothesis that disorganized attachment in early childhood may be a signifi cant predictor of the development of dissociative symptoms [22,23].
Although with earlier studies, Van IJendo has analyzed a large number of studies, precisely eighteen, about the intergenerational transmission of the attachment style, some concerning the mother-child dyad, others (only four) referring to the father. The author has found proper levels of correlation between the Safe attachment style of the parent and the Safe of the child and the Distancing style of the parent and the Avoidant style of the child, while the data are less encouraging regarding the analogy between the Involved style of the parent and the ambivalent child who does not seem to agree signifi cantly with each other. In summary, the cited researches fi nd that a mother with a secure attachment style will tend to have a child who is also safe, just as a mother with an avoidant attachment will have a child with the same attachment style; the association between the mother's Involved attachment style and the child's Ambivalent attachment does not appear to be confi rmed. The authors interpret the similarities found between the style of maternal attachment and the quality of the child's attachment to the mother, such as the expression of a continuity in the qualitative characteristics of the internal working models of the adult's attachment that are proposed to the child through the mother's care behaviours: in particular sensitivity and responsiveness. On the whole, however, these studies follow a principle of direct transmission of the maternal representation of attachment in infancy which today appears to be overcome by a series of theoretical refl ections and empirical tests that "relativize" the continuity of the intergenerational transmission of attachment [22].
The DSM-V Manual identifi es some psychopathological forms related to a dysfunctional attachment, bearing in mind that this condition can easily lead to the onset of other psychopathologies, in comorbidity [24].
Severe conditions of neglect and traumatic experiences, occurring from the fi rst months of life, can give rise to the "Reactive-Inhibited Attachment Disorder" (RAD) or the "Disinhibited Social Engagement Disorder" (DSED). The RAD and DSED are two different symptomatological frameworks that have many aspects in common, especially about the aetiology. Both disorders share the diagnostic requirement of social neglect (i.e. the absence of adequate care during childhood) and arise due to an environment characterized by abuse and the impossibility of developing an attachment relationship with the caregiver (for frequent changes in carers' caregivers). The substantial difference lies in the two different reference constructs: inhibition vs disinhibition. The RAD is expressed as an internalizing disorder with depressive symptoms and withdrawn behaviour; DSED is characterized by disinhibition and externalizing behaviour [24].
The primary manifestation of the RAD [25][26][27][28] is the avoidance of caregivers; in fact, the child rarely seeks their support and comfort when he feels discomfort and responds to a minimum when it is offered. These children are not interested in games typical of their peers; they tend to isolate themselves and, when they are frustrated, they often put in place aggressive behaviour towards those around them. They are children who smile very little because the only emotions they experience are negative. Indeed, they oscillate between sadness, anxiety, fear and irritability. In a context characterized by humiliation and lack of comfort/support/ protection by caregivers, these children soon develop a vision of themselves, of others and the world based on contents of personal inadequacy. Therefore, in the presence of such early experiences, withdrawal and avoidance are protective responses to pain and suffering. The DSM-V diagnostic criteria are: institutions with high child-caregiver relationships).
d) It is assumed that the treatment of criterion C was responsible for the disturbed behaviour in criterion A.
e) The criteria are not met for autism spectrum disorders.
f) The disorder is evident before the age of 5.
g) The child has an evolutionary age of at least 9 months.
The DSM-V suggests specifying whether the disorders have been present for more than 12 months (and therefore assumes the characteristics of persistence) and whether it should be considered severe (i.e. when a child exhibits all the symptoms of the disorder, and each symptom manifests itself in relatively high levels).
Children with DSED manifest a series of behaviours (verbal or physical) excessively familiar and without inhibition in the approach and the interaction with unknown adults, so much so that they do not show any reticence and hesitation to get away with them. They manifest a general and marked happiness when they come into contact with strangers, an aspect that, however, may be completely absent from caregivers. When strangers reject their emotions and their search for attention, they begin to manifest high levels of anxiety and frustration.
Uninhibited social behaviour also extends into adolescence and is directed at the peer group, with which superfi cial and confl ict-based relationships are soon established. These children have no remorse, no guilt or regret when they hurt or disappoint people around them. Uninhibited behaviour is established because of children, since caregivers do not satisfy their emotional needs and do not protect them, begin to look for others who can do so, in a friendly and excessively familiar manner. The DSM-V diagnostic criteria are: a) A behavioural pattern in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following: -reduced or absent reticence in approach and interaction with unfamiliar adults; -excessively familiar verbal or physical behaviour (inconsistent with culturally established and ageappropriate social boundaries); -decreased or absent research of the adult caregiver after having moved away from it, even in unfamiliar settings; -Willingness to leave with an unfamiliar adult with minimal hesitation or without.
b) The behaviours listed in criterion A are not limited to impulsiveness (as in ADHD) but include socially uninhibited behaviour.
c) The child has experienced an extreme or insuffi cient pattern of care, as evidenced by at least one of the following: -social neglect or deprivation in the form of persistent lack of basic emotional needs of comfort, stimulation and affection of parental care; -repeated changes of primary caregivers that have limited opportunities to form stable attachments (e.g. frequent changes of foster care); -Breeding in unusual contexts that have severely limited opportunities to form selective attachments (e.g. institutions with high child-caregiver relationships).
d) It is assumed that the treatment of criterion C was responsible for the disturbed behaviour in criterion A.
e) The child has an evolutionary age of at least 9 months.
The DSM-V suggests specifying whether the disorders have been present for more than 12 months (and therefore assumes the characteristics of persistence) and whether it should be considered severe (i.e. when a child exhibits all the symptoms of the disorder, and each symptom manifests itself in relatively high levels).
Recently, there has also been "mixed" symptomatology (that is characterized both by symptoms of the RAD and by symptoms of the DSED) which tends to remain despite being placed in contexts with better conditions of care [24]. 1) "Distortions of the secure base". Various forms demonstrate an evident distortion of the secure base: altered perception of danger, exasperated / inhibited exploration not counterbalanced by a healthy search for caregiver proximity, excessive complacency, hypercontrolled or reduced or absent vigilance, a reversal of roles with excessive concern by the child about the emotional and personal well-being of his caregiver.
2) "Attachment-free disorders", in which the child does not show a preference for an adult who looks after him. Emotional withdrawal is present, with signifi cant inhibition of comfortseeking behaviours, affection manifestation, search for help and cooperation. The disorder manifests the absence of attachment with indiscriminate sociability. The child looks for social interactions with strangers without the discrimination and reticence of children in this age group.
3) "Interrupted attachment disorder". This disorder begins after a traumatic experience of separation that the child has experienced, separation from the mother or caregivers following a loss or following frequent experiences of separation. The child who suffers from this disorder has internal contradictions that are observable also from the behavioural point of view. Ageless, confusion, inability to adopt a non-dysfunctional behaviour are the signals. For example, the mother takes the child in her arms, and he looks elsewhere, taking an unfriendly and disconnected attitude.