Saturday, April 13, 2013

Attachment and Substances, in depth

As a clinician treating adolescents and young adults with addictive disorders, it has become increasingly apparent that affect dysregulation and a related difficulty with turning to others for emotional soothing contribute to the onset of drug use, continued use, and relapse. Affect regulation is a primary issue of focus in treatment for sustained recovery. The challenge for the user is learning to recognize and experience their own emotional states, understand their need for support, build social connection, and trust that they can turn to others to regulate themselves instead of turning to drugs, drug dealers and drug culture.
As a pre-teen enters the adolescent phase of life, powerful internal struggles emerges. These years encompass many social changes as well as internal changes (Cozolino, 2006). Change, whether good or bad, is the common denominator for stress. Adolescence is a time of significant change. During this time of change, the brain and mind is reorganizing itself during its last period of neural growth and connection. Then myelination starts to occur in early twenties, a process where many major pre-existing neural connections become more solidified (Giedd et al 1996; Pfefferbaum et al 1994; Spear, 2000; Yurgelun-Todd et al 2002). Changes which take place prior to myelination, especially earlier in childhood, have profound effects upon personality and attachment over the lifetime (Siegel, 1999).
Substance use trends
The use of intoxicating substances has been an accompanying part of American society for some time. Drug use researchers have seen trends influenced by several variables, most notably by availability of a drug, overall societal and teen attitudes and beliefs about use, prevention efforts, and drug policy.
A 32-year comparison of teen drug use trends and attitudes found that overall, between 1979 and 2006,
Much data on the topic has been collected an analyzed. Two themes of interest to the present study are that the average age of first intoxication has become increasingly younger, though metrics vary on the exact age, it appears that most teens become initiated into use between 6th grade and
There is no question that the number of adolescents using alcohol and illicit drugs is of great concern, and that there are many variables contributing to the epidemic. In 2008 the benchmark index, Monitoring the Future annual survey, used by clinicians and researchers to track the trends of adolescent drug use, found that 19.6% of 8th graders and 47.4% of high school seniors have used illicit drugs in their lifetime. More specifically, 11.2% of 8th graders and 24.9% of seniors tried marijuana. 15.7% of 8th graders and 9.9% of seniors tried inhalants and finally 15.9% of 8th graders and 43.1% of seniors have used alcohol within the past 30 days. This survey also showed that from 1991 to 1999 the prevalence illicit drug use has nearly doubled. (Johnston et al., 2009).
More than one-quarter (1.8 million) of alcohol-dependent adults, age 21 or older in 2003, had first used alcohol before age 14. Over eighty percent, 5.1 million, had first used before they were age 18. Ninety-six percent, 6.0 million, had first used before age 21. (Curie, 2005)
On any given day, 100 million Americans use one of the following drugs: legal stimulants, antidepressants, tranquillizers, or painkillers; nicotine, aerosol or glue inhalents, alcohol, marijuana, cocaine, heroin, methamphetamines, hallucinogens, ecstasy, and other designer drugs. (Califano, 2007).
Another alarming trend is that while the prevalence of drug-using teens has increased over the years, the age of onset of first intoxication has decreased. In large, longitudinal study by Dawson & Dawson, it was found that if a person started using drugs at age 13 or younger they had a 42% chance of having substance dependence. If a person also had a genetic family history of addiction, then the chance increased by 15% (Grant BF, Dawson DA 1998).
In 2006, hospitals in the United States delivered a total of 113 million Emergency Department (ED) visits, and the Drug Abuse Warning Network (DAWN) estimates that 1,742,887 ED visits were associated with drug misuse or abuse. Of those ED visits: 31% involved illicit drugs only, 28% involved pharmaceuticals only, 7% involved alcohol only in patients under the age of 21, 13% involved illicit drugs with alcohol, 10% involved alcohol with pharmaceuticals, 8% involved illicit drugs with pharmaceuticals, and 3% involved illicit drugs with pharmaceuticals and alcohol.
Alcohol in patients under age 21 DAWN estimates to be 76,760 alcohol-related ED visits for patients aged 12 to 17, and 105,675 alcohol-related ED visits for patients aged 18 to 20. About two thirds (69%) of the alcohol-related ED visits for minors involved alcohol and no other drug. The rate of alcohol-only ED visits for patients aged 18 to 20 (581 visits per 100,000 population) was 2.8 times that for patients aged 12 to 17 (204 per 100,000), and males and females had similar rates (Substance Abuse and Mental Health Services, 2008). Clearly, the use of intoxicating substances by young people has far-reaching effects upon American society.
Attachment, attunement, and dysregulation
Over the past 60 years, attachment theory has shown that when children are raised by parents who are warm, reflective, consistent and attuned to their child's needs, it not only builds the affect regulation system in them psychologically, but biologically as well (Schore 2003 & Seigel 1999).
Attachment theory began with the work of John Bowlby and was advanced in the 1960s by Mary Ainsworth as a result of her application of the empirical process to the theory. Her work which linked naturalistic observation techniques to the study of the relationship between a mother and child when together, separated and during reunion resulted in the Strange Situation study. Since then is has been one of the most reviewed and replicated studies in developmental psychology. The resulting work has classified attachment into various well-substantiated categories (Armsden & Greenberg, 1987; Ainsworth et al 1978; Cassidy & Shaver, 1999)
The adolescent years may be a naturally occurring strange situation. During the elementary school experience, most kids are with the same students and teacher each day. Thoughts of romantic attachments have not yet occurred, and social skills used for connecting with others are fairly simple. However, high school can be a time where kids are with different kids and different teachers 4 – 6 times a day as they move to new classrooms to learn new subjects. Peers start to form social cliques, romantic feelings begin to arise, and social skills become increasingly sophisticated to match relationships which are becoming increasingly sophisticated. For the insecurely attached teen this can elicit a heightened state of anxiety and a taxing of their adaptational resources.
Researchers have shown that attachment is related to peer relationships and peer competence across developmental periods (Elicker, Englund, & Sroufe, 1992). Popularity, aggression, self-esteem, and the emergence of mental health issues such as depression all arise during adolescence, and have been correlated with attachment style (Armsden & Greenberg, 1987; Cohn, 1990; Nada Raja, McGee, & Stanton, 1992; DeMulder, Denham, Schmidt, & Mitchell, 2000; DeMulder et al., 2000).
The parent-child relationship is also correlated with peer social skills in preschoolers (Pianta et al., 1997). Cassidy, Kirsh, Scolton, and Parke (1996)found that children securely attached to their mothers more often believe that their peers have positive intent in ambiguous situations, which supports the notion that early attachment experiences for the child with the caregiver cast forward far reaching implications for peer interactions. Freitag et al (1996) found secure attachments may foster social competence during middle childhood, likely impacting a friendship quality. Self-reports of security with one’s mother have been shown to relate to fifth graders’ acceptance by their peers and their behavior with friends (Kerns, Cole, & Klepac, 1996). Peer competence is also indicated as mediated by attachment adolescents (Allen et al., 1998).
Attachment bonds are not only important for general well being, but build the template and expectation for all relationships across the lifespan (Waters et al., 2000). As early as infancy, children can mentally represent their attachment figures and construct ideas and expectations for relationships with both these original figures and others. Bowlby called this the internal working model "IWM" of attachment. Bowlby believed that starting in infancy a child internalizes patterns of relating to people, generally the parents, and forms an idea of how to relate to others based on these representations (1988). It is also thought of as the underlying structure that shapes the nature of sensation, perception, memory, feeling, thought and behavior and is likely to get consolidated as personality or personality disorders (Cozolino, 2006). Through early interactions with caregivers, children internalize and organize their understanding of relationships (Laursen & Collins, 2004).
Biologically, the dopamine and opiate system fire and during the attuned experience between parent and child which biologically serves as a significant piece to the biology of attachment. During infancy these systems develop to create a pleasurable experience when the caregiver attunes to a child's needs. As the dopaminergic system and opiate systems are built and firing in this situation, the hedonic state serves to become the seeking (desire) and reinforcing (reward) systems. This plays out in the attachment relationship as a child's neurochemistry is reinforcing using other human beings for affect regulation. If the child turns to others to be soothed only to be left alone emotionally, which creates shame, a painful experience. Subsequently, the development of the two aforementioned systems mentioned is thwarted (Schore 2003, Siegel 1999). Avoiding others when affect is dysregulated becomes reinforced. As noted in the beginning of the article, it has been observed by the author that this dynamic fuels addictive disorders.
When people use drugs dopamine and the opiate system are activated (Wise, 1996). These are the same systems operating during parent child bonding in the early formative years of life. It is suspected by the researcher that drugs become the substitute for healthy co-regulation. Furthermore, it has been observed by the researcher that chemically dependent teens quickly learn to trust that drug dealers and drug culture will respond to their need for closeness, belonging, warmth and soothing.
In 2007, a large study of teens found that they were significantly more likely to think that kids use drugs to help relieve the pressures and stress of school (73%) than they were to see use as a means to have fun (26%). An accompanying study of parents’ attitudes showed a severe disconnection. Only 7% of parents believed that teens might use drugs to cope with stress. This research highlights a societal misattunement between caregiver and child (PATS, 2007).
Gaps in the literature
Peer reviewed research linking attachment trends with substance use is sparse at best. Most research is preliminary or purely theoretical. Lyvers & Thorberg (2006) compared attachment trends of chemically dependent adults in inpatient treatment with self-report "no history of substance problems" university students and workers. Insecure attachment was significantly higher in the chemically dependent group, though the groups were not otherwise demographically homogeneous in several important areas, including gender, an the sample sizes were small.
Probably the most cited and respected work on the present topic problem was completed by Cooper, Shaver & Collins (1998). In a study of 1,989 adolescents, it was discovered that high-risk behaviors, including substance use, were significantly higher among participants with problematic attachments to primary caregivers and peers.
In the absence of secure attachment, and more specifically a soothing internal working model, people are much more vulnerable to developing pathological self-soothing behaviors (Cozolino, 2006). It is suspected by the researcher that seeking intoxication is one of these affect-regulating behaviors. The present study seeks to explore a link between proximity to problematic substance use and attachment.

Ainsworth, M. D. (1978). Patterns of attachment: a psychological study of the strange situation. Hillsdale, N.J.: Lawrence Erlbaum Associates.

Armsden, G. C., & Greenberg, M. T. (1987). The inventory of parent and peer attachment: Individual differences and their relationship to psychological well-being in adolescence. Journal of Youth & Adolescence, 16(5), 427-454.

Califano, J. A. (2007). High society: how substance abuse ravages america and what to do about it. New York: Public Affairs.

Cassidy, J., & Shaver, P. R. (1999). Handbook of attachment: theory, research, and clinical applications. New York: Guilford Press.

Cassidy, J., Kirsch, S. J., Scolton, K. L., & Parke, R. D. (1996). Attachment representations of peer relationships. Developmental Psychology, 32(5), 892-904.

Cohn, D. A. (1990). Child-mother attachment of six-year-olds and social competence at school. Child Development, 61, 152-162.

Cooper, M. L., Shaver, P. R., & Collins, N. L. (1998). Attachment styles, emotional regulation, and adjustment in adolescenc. Journal of Personality & Social Psychology, 75(5), 1380-1397.

Cozolino, L. J. (2006). The neuroscience of human relationships: attachment and the developing social brain. New York: Norton.

Curie, C. (2005, April 26). U.S. Department of Health and Human Services on Substance Abuse Prevention Programs of the Substance Abuse and Mental Health Services. Address presented at Administration before Subcommittee on Criminal Justice, Drug Policy and Human Resources Committee on Government Reform in US House of Representatives, Washington, DC.

DeMulder, E. K., Denham, S., Schmidt, M., & Mitchell, J. (2000). Q-sort assessment of attachment security during the preschool years: Links from home to school. Developmental Psychology, 36(2), 274-282.

Elicker, J., Englund, M., & Sroufe, L. A. (1992). Predicting peer competence and peer relationships in childhood from early parent-child relationships (R. D. Parke & G. W. Ladd, Eds.). In Family-peer relationships: modes of linkage (pp. 77-106). Hillsdale, N.J.: L. Erlbaum Associates.

Freitag, M. K., Belsky, J., Grossmann, J., Grossmann, K., & Scheuerer-Englisch, H. (1996). Continuity in parent-child relationships from infancy to middle childhood and relations with friendship competence. Child Development, 67(4), 1437-1454.

Giedd, J. N., Snell, J. W., Lange, N., Rajapakse, J. C., Casey, B. J., Kozuch, P. L., Rapoport, J. L. (1996). Quantitative magnetic resonance imaging of human brain development ages 4-18. Cerebral Cortex, 6, 551-560.

Grant, B. F., & Dawson, D. A. (1998). Age of onset of drug use and its association with DSM-IV drug abuse and dependence: Results from the National Longitudinal Alcohol Epidemiologic Survey. Journal of Substance Abuse, 10, 163-173.

 Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2007). Monitoring the Future national survey results on drug use, 1975-2006: Volume I, Secondary school students (NIH Publication No. 07-6205). Bethesda, MD: National Institute on Drug Abuse.

Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2009). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2008 (NIH Publication No. 09-7401). Bethesda, MD: National Institute on Drug Abuse.
Kerns, K. A., Cole, A., & Klepac, L. (1996). Peer relationships and preadolescents’ perceptions of security in the child-mother relationship. Developmental Psychology, 32(3), 457-466.

Lyvers, M., Thorberg, F. A. (2006). Attachment, fear of intimacy and differentiation of self among clients in substance disorder treatment facilities. Faculty of Humanities and Social Sciences: Humanities & Social Science Papers, Bond University.

Nada Raja, S., McGee, R., & Stanton, W. R.  (1992).  Perceived attachments to parents and peers and psychological well-being in adolescence.  Journal of Youth and Adolescence, 21(4), 471-485.

The Partnership Attitude Tracking Survey (PATS).  Teens 2007 Report; Released August 4, 2008;

Pefeferbaum, A., et al. 1994. A quantitative magnetic resonance imaging study of changes in the brain morphology from infancy to late adulthood.  Arch. Neurol. 51, 874-887.

Pianta, R. C., Nimetz, S. L., & Bennett, E.  (1997).  Mother-child relationships, teacher-child relationships, and school outcomes in preschool and kindergarten.  Early Childhood Research Quarterly, 12, 263-280.

Schore, A.N. Affect Dysregulation and Disorders of the Self. New York: W.W. Norton, 2003.

Daniel J. Siegel. The Developing Mind: Toward a Neurobiology of Interpersonal Experience. New York, The Guilford Press, 1999.

Spear, L.P. 2000. The adolescent brain and age-related behavioral manifestations. Neurosci. Biobev. Rev, 24, 417-463.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Drug Abuse Warning Network, 2006: National Estimates of Drug Related Emergency Department Visits. DAWN Series D-30, DHHS Publication No. (SMA) 08-4339, Rockville, MD, 2008.

Waters, E., Merrick, S., Treboux, D., Crowell, J., Albersheim, L. (2000). Attachment security in infancy and early adulthood: a twenty-year longitudinal study. Child Development, 71(3), 684-689.

Wise, R. A. (1996). Neurobiology of addiction. Current Opinion in Neurobiology, 6(2), 243-251.

Yurgelun-Todd, D. et al. 2002. Sex differences in cerebral tissue volume and cognitive performance during adolescence. Psych. Rep., 91: 743-757.

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