case study of child psychology

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

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There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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Module 13: Disorders of Childhood and Adolescence

Case studies: disorders of childhood and adolescence, learning objectives.

• Identify disorders of childhood and adolescence in case studies

Case Study: Jake

Jake was born at full term and was described as a quiet baby. In the first three months of his life, his mother became worried as he was unresponsive to cuddles and hugs. He also never cried. He has no friends and, on occasions, he has been victimized by bullying at school and in the community. His father is 44 years old and describes having had a difficult childhood; he is characterized by the family as indifferent to the children’s problems and verbally violent towards his wife and son, but less so to his daughters. The mother is 41 years old, and describes herself as having a close relationship with her children and mentioned that she usually covers up for Jake’s difficulties and makes excuses for his violent outbursts. [1]

During his stay (for two and a half months) in the inpatient unit, Jake underwent psychiatric and pediatric assessments plus occupational therapy. He took part in the unit’s psycho-educational activities and was started on risperidone, two mg daily. Risperidone was preferred over an anti-ADHD agent because his behavioral problems prevailed and thus were the main target of treatment. In addition, his behavioral problems had undoubtedly influenced his functionality and mainly his relations with parents, siblings, peers, teachers, and others. Risperidone was also preferred over other atypical antipsychotics for its safe profile and fewer side effects. Family meetings were held regularly, and parental and family support along with psycho-education were the main goals. Jake was aided in recognizing his own emotions and conveying them to others as well as in learning how to recognize the emotions of others and to become aware of the consequences of his actions. Improvement was made in rule setting and boundary adherence. Since his discharge, he received regular psychiatric follow-up and continues with the medication and the occupational therapy. Supportive and advisory work is done with the parents. Marked improvement has been noticed regarding his social behavior and behavior during activity as described by all concerned. Occasional anger outbursts of smaller intensity and frequency have been reported, but seem more manageable by the child with the support of his mother and teachers.

In the case presented here, the history of abuse by the parents, the disrupted family relations, the bullying by his peers, the educational difficulties, and the poor SES could be identified as additional risk factors relating to a bad prognosis. Good prognostic factors would include the ending of the abuse after intervention, the child’s encouragement and support from parents and teachers, and the improvement of parental relations as a result of parent training and family support by mental health professionals. Taken together, it appears that also in the case of psychiatric patients presenting with complex genetic aberrations and additional psychosocial problems, traditional psychiatric and psychological approaches can lead to a decrease of symptoms and improved functioning.

Case Study: Kelli

Kelli may benefit from a course of comprehensive behavioral intervention for her tics in addition to psychotherapy to treat any comorbid depression she experiences from isolation and bullying at school. Psychoeducation and approaches to reduce stigma will also likely be very helpful for both her and her family, as well as bringing awareness to her school and those involved in her education.

• Kolaitis, G., Bouwkamp, C.G., Papakonstantinou, A. et al. A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability, and 47,XXY syndrome in combination with a 7q11.23 duplication, 11p15.5 deletion, and 20q13.33 deletion. Child Adolesc Psychiatry Ment Health 10, 33 (2016). https://doi.org/10.1186/s13034-016-0121-8 ↵
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• A boy with conduct disorder (CD), attention deficit hyperactivity disorder (ADHD), borderline intellectual disability.... Authored by : Gerasimos Kolaitis, Christian G. Bouwkamp, Alexia Papakonstantinou, Ioanna Otheiti, Maria Belivanaki, Styliani Haritaki, Terpsihori Korpa, Zinovia Albani, Elena Terzioglou, Polyxeni Apostola, Aggeliki Skamnaki, Athena Xaidara, Konstantina Kosma, Sophia Kitsiou-Tzeli, Maria Tzetis . Provided by : Child and Adolescent Psychiatry and Mental Health. Located at : https://capmh.biomedcentral.com/articles/10.1186/s13034-016-0121-8 . License : CC BY: Attribution
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• Volume 32, Issue 6
• Very early family-based intervention for anxiety: two case studies with toddlers
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• http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
• Aude Henin 1 , 2 ,
• Stephanie J Rapoport 1 ,
• Timothy E Wilens 2 , 3 and
• Alice S Carter 4
• 1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
• Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• childhood anxiety disorders
• preschoolers
• cognitive behavioural therapy

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

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Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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CLINICAL CASE STUDY article

“a child’s nightmare. mum comes and comforts her child.” attachment evaluation as a guide in the assessment and treatment in a clinical case study.

• Department of Developmental and Socialization Psychology, University of Padova, Padova, Italy

There is a gap between proposed theoretical attachment theory frameworks, measures of attachment in the assessment phase and their relationship with changes in outcome after a psychodynamic oriented psychotherapy. Based on a clinical case study of a young woman with Panic Attack Disorder, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the psychodynamic diagnostic manual. Treatment planning and post-treatment changes were described with the main aim to illustrate from a clinical point of view why a psycho-dynamic approach, with specific attention to an “attachment theory stance,” was considered the treatment of choice for this patient. The Symptom Check List 90 Revised (SCL-90-R) and the Shedler–Westen Assessment Procedure (SWAP–200) were administered to detect patient’s symptomatic perception and clinician’s diagnostic points of view, respectively; the Adult Attachment Interview and the Adult Attachment Projective Picture System (AAP) were also administered as to pay attention to patient’s unconscious internal organization and changes in defense processes. A qualitative description of how the treatment unfolded was included. Findings highlight the important contribution of attachment theory in a 22-month psychodynamic psychotherapy framework, promoting resolution of patient’s symptoms and adjustment.

Introduction

Attachment theory in Bowlby’s (1969/1982 , 1973 , 1980 , 1988 ) and Ainsworth’s (1963 , 1967 ) tradition postulates that an individual’s experience of early parental care contributes to the development of internal representations of self and others as safe and available. This theory offered the clinicians a scientific grounded model, which postulated and empirically demonstrated the origin of psychopathology in early separation experiences and in adverse emotional experiences ( Oppenheim and Goldsmith, 2007 ; Cassidy and Shaver, 2008 ). The most recent literature endorses that attachment theory is consonant with all assessment and treatment approaches which evaluate childhood experiences as an important contributor to adult functioning (e.g., Wallis and Steele, 2001 ; Blatt and Levy, 2003 ; Diamond, 2004 ; Bakermans-Kranenburg et al., 2005 ; Buchheim et al., 2007 ; Zegers et al., 2008 ; Buchheim and George, 2011 ). Throughout the case formulation and the planning of treatment, attachment theory has also the potential to provide-at least-a useful foundation for defining the target of change in psychotherapy (e.g., features of internal working models or attachment patterns), understanding the processes through which change occurs (e.g., through the development of a secure base and exploration of working models; e.g., Fonagy, 1999 , 2001 ; Cozzolino, 2002 ; Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Wallin, 2007 ; Fosha, 2009 ; Holmes, 2010 ; Siegel, 2010 ). As Bowlby originally stated, while reconsidering classical attachment theory, Davila and Levy 2006 , p. 990) stressed “five key tasks for psychotherapy: (a) establishing a secure base, which involves providing patients with a secure base from which they can explore the painful aspects of their life; (b) exploring past attachments, which involves helping patients explore past and present relationships, including their expectations, feelings, and behaviors; (c) exploring the therapeutic relationship, which involves helping the patient examine the relationship with the therapist and how it may relate to relationships or experiences outside of therapy; (d) linking past experiences to present ones, which involves encouraging awareness of how current relationship experiences may be related to past ones; and (e) revising internal working models, which involves helping patients to feel, think, and act in new ways that are unlike past relationship.” Despite the increasing interest in the relevance of attachment theory as a framework to understand the unfolding of psychodynamic treatment, there is a gap between the proposed theoretical frameworks and the empirical measures of attachment used in the assessment, and only few studies addressed the interplay between attachment pattern measures, and their implication for unfolding and outcome in a psychoanalytic oriented treatment ( Buchheim and Kachele, 2001 ; Dahlbender et al., 2004 ; Buchheim, 2005 ; Lis et al., 2008 , 2011 ; Isaacs et al., 2009 ).

Interpersonal problems, adult attachment, and emotion regulation have been increasingly studied across adult anxiety disorders. Literature linked attachment and separation in infants and preschool children to separation anxiety disorder, agoraphobia, and panic attacks later in life, underlining how insecure attachment can lead to an increased risk for attachment psychopathology and subsequent social and emotional maladjustment/attachment and separation anxiety/school or work phobia/attachment correlations ( Routh and Bernholtz, 1991 ). Of all the forms of anxiety, separation anxiety seems to be the one which is most likely to be associated with an anxious attachment style, because sufferers are by definition highly sensitive to real or perceived threats to relationships ( Main et al., 1985 ). Separation anxiety would appear to be a core form of anxiety associated with panic attack disorder and with attachment problems ( Hazan and Shaver, 1987 ; Bartholomew and Horowitz, 1991 ; Eng et al., 2001 ). Dysfunctional and not good-enough parenting and hereditary factors appear to play a role in generating early separation anxiety. However, the child’s anxiety itself may generate overprotective parenting ( Manicavasagar et al., 1999 , 2009 ) which, in turn, could make children approach their caregivers both in response to dangerous external stimuli and to caregiver’s permanent monitoring availability and attentiveness; moreover, overprotecting or over responsive parents could obstacle the expression of the explorative system, even when a “secure base” is provided ( Pacchierotti et al., 2002 ). Although attachment theory suggests that anxious attachment styles are mostly associated with risks of developing anxiety disorders, neither all anxious attached patients develop panic attack disorder, nor all secure attached patients do not develop it: the latter is a weird and rare condition because, theoretically, secure early relationships with adults are the basis for the development of a sense of control and predictability accounting for normal subjects’ tendency not to interpret ambiguous internal stimuli as threatening ( Shear, 1991 ).

Based on a clinical case study of a young woman with Panic Attack Disorder- Matilde-, this paper examined psychotherapy outcome findings comparing initial and post-treatment assessments, according to the mental functioning in S and M -axis of the Psychodynamic Diagnostic Manual (PDM; PDM Task Force, 2006 ) 1 . The patient’s choice is motivated by this “rare combination”: a PAD patient with secure attachment. The first aim of this paper was to provide incremental usefulness to the picture of the patient’s idiographic and intra-subjective features, using a multi- method assessment based on (1) two performance-based attachment measures – the Adult Attachment Interview (AAI; George et al., 1984 / 1985 / 1996 ), and The Adult Attachment Projective Picture System (AAP; George and West, 2001 , 2012 ), (2) the Shedler–Westen Assessment Procedure (SWAP–200; Westen and Shedler, 1999a , b ), and (3) a self-report symptom scale, the Symptom Checklist 90 Revised (SCL-90-R; Derogatis, 1983 ; Funder, 1997 ; Meyer et al., 1999 ; Ozer, 1999 ).The second aim was to describe how Matilde’s assessment findings – and more specifically attachment pattern analysis – could represent useful guidelines for the unfolding of a psychoanalytic therapy with a supportive approach, in an attachment theory framework ( Misch, 2000 ).

We hypothesized that the AAI, the AAP, the SCL-90-R, and the SWAP–200 would help in focusing on the most relevant dimensions of patient’s psychological functioning which make a meaningful diagnosis ( Barron, 1998 ; Shedler and Westen, 2007 ) at the beginning and at the end of treatment. Attention was directed to the interplay between modification of overt symptoms and behaviors, and changes in personality functioning and adaptation; more specifically, we focused on patterns and complexities in the patient’s internal organization and interpersonal functioning ( Shectman and Harty, 1986 ; Peebles-Kleiger, 2002 ; Bram, 2010 ). A reduction in psychopathological symptoms and an improvement in mental functioning according to the PDM M -axis and S -axis were expected at the end of the therapy.

Clinical Case Presentation: Matilde

Matilde was a pleasant 20-year-old young woman, who looked younger than her age. She was a self-referred patient, and was assessed for a high level of anxiety at a university-based psychology-training clinic 2 . Matilde had a diagnosis of Panic Attack Disorder in Axis I (DSM-IV; American Psychiatric Association [APA], 1994 ), and no diagnosis in Axis II. Although she was a 2-year student at the Medical School with outstanding results, she felt “ anxious, confused, and insecure, ” “ I do not know if this Faculty is good for me, maybe Biology would be better, or Pharmacy … I do not know really, I am so confused; I do not understand what is happening to me …. I am no more sure about anything. ” Insecurity caused her quite severe crying crises, pervasive anxiety, and some physical symptoms, such as psychomotor agitation and tachycardia. She had taken light tranquilizers in the last 3 months. She felt unable to control or understand her present distress. Since she started University, her life had been totally busy with studying, leaving no time or desire to engage in social relationships. She did not talk about any actual satisfying relationships. The only “ friends ” she kept in touch with were schoolmates from high school, with whom she shared school topics. She had never had a boyfriend, and felt very uncomfortable talking about romantic or sexual topics. Matilde moved away from her small native town to attend University, and she was sharing an apartment with other students next to the Medical School. She went back home to her family during University vacations. She came from an intact family, which she was very proud of. She had a 10-year-old sister, Sarah, to whom she was very attached. Sarah was described as very different from Matilde: very funny, an ironic with a lot of energy. They spent a lot of time playing together, and Matilde was unconcerned about her worries when she was with Sarah. Matilde describes her childhood with some enjoyment and unconcern while her present appears very worrying, uncertain and without any source of protection and soothing. Matilde supports a good relation with her mother, although the father is described as rigid and very involved in practical duties.

Approach to the Case: Procedure and Instruments

At the initial assessment phase Matilde underwent three interview sessions, two test sessions and one feedback session. In particular, Matilde’s evaluation involved the administration of the AAI and the AAP, the SCL-90-R, and the SWAP–200. All results were integrated with clinical interview contents to formulate a case conceptualization, according to specific dimensions of the PDM. In the feedback session, a once-a-week psychodynamic psychotherapy with a supportive approach was proposed to and accepted by Matilde. The therapy lasted 22 months. At treatment conclusion Matilde accepted to be re-administered the AAP and the SCL-90-R. Based on the last three sessions also the SWAP–200 was re-administered. All the tools administered were scored and interpreted by independent judges 3 . A brief description of used tools follows after timetable of administration (Table 1 ).

TABLE 1. Timetable of administered tools.

Symptom Checklist 90 Revised ( Derogatis, 1983 ) is a 90-item self-report questionnaire scored on a five-point Likert scale of distress from 0 (none) to 4 (extreme), indicating the rate of occurrence of symptoms during the time reference ( Derogatis et al., 1973 ). It is intended to measure symptom intensity on 10 different dimensions: somatization (SOM), obsessive–compulsive (O–C), interpersonal sensitivity (I-S), depression (DEP), anxiety (ANX, hostility (HOS), phobic anxiety (PHOB), paranoid ideation (PAR), psychoticism (PSY), and sleep difficulties (SLEEP). A Global Severity Index (GSI) of distress is calculated. According to the Italian Manual, an intensity raw score higher than one was qualified as penetrating in the clinical range. The internal consistency coefficient alphas for the nine symptom dimensions ranged from 0.77 for Psychoticism, to 0.90 for Depression. Test–retest reliability coefficients ranged between 0.80 and 0.90 after 1 week of therapy. The few validity studies of the SCL-90-R demonstrate levels of concurrent, convergent, discriminant, and construct validity comparable to other self-report inventories ( Derogatis, 1983 ).

The Shedler–Westen Assessment Procedure ( Westen and Shedler, 1999a , b ) is a set of 200 personality-descriptive statements developed for clinicians to assess adult personality traits and pathologies ( Shedler and Westen, 1998 ). Starting from clinical interviews, the assessor is asked to describe the patient by arranging the statements into eight categories, from those that are not descriptive (assigned a value of “0”) to those that are highly descriptive (assigned a value of “7”) for each of the 200 personality-descriptive variables. The instrument is based on the Q-sort method that requires clinicians to arrange items into a fixed distribution ( Block, 1978 ). The SWAP–200 could be interpreted at a nomothetic as well as at an idiographic level. Nomothetic interpretations are carried out following two profiles. The first is the PD-T score profile of the 10 Personality Disorders included in DSM–IV (paranoid, schizoid, schizotypal, antisocial, borderline, histrionic, narcissistic, avoidant, dependent, obsessive); the Q-T profile covers 11 dimensions (psychological health, dysphoric, antisocial, schizoid, paranoid, obsessive, histrionic, narcissistic, avoidant, depressive high functioning, emotional dysregulation, dependent, hostile). Both PD-T and Q-T profiles include a score on a Healthy Functioning scale. Inter-rater reliability coefficients range from 0.70 to 0.80. Support for the validity of the SWAP–200 is derived from its ability to predict relevant variables in expected ways, including family psychiatric history, history of abuse, social, and school functioning, violence, suicidal behaviors and attempts, attachment status, and eating disorder diagnostic groups ( Westen and Muderrisoglu, 2003a , b ). Idiographic narrative case description is also included in the SWAP–200 (e.g., Lingiardi et al., 2006 ). Both levels were used to assess Matilde. Moreover, the SWAP–200 ( Westen and Shedler, 1999a , b ) is one of the instruments listed by PDM work-group members to be used to measure the dimensions of the M -axis.

The Adult Attachment Interview ( George et al., 1984 , 1985 , 1996 ; Hesse, 2008 ) is an about 1 h audio-recorded semi-structured interview that explores an adult’s mental representations of attachment, guiding the individual through a series of questions about past and present relationships with each parent and attachment-relevant events during childhood. The AAI focuses on the assessment of the attachment internal working model ( Bowlby, 1969/1982 ) and assumes developmental continuity of the attachment system along life. AAI final attachment classification is evaluated on two different set of scales (1) Experience Scales that evaluate for example Loving, Rejecting, Neglect, Role Reversal, Pressure to achieve and (2) State of Mind Scales that assess Coherence, Metacognitive Processes, Lack of Recall, Passivity of Discourse, Idealization, Anger, Derogation attitudes toward caregivers, Unresolved mourning or trauma, Feared loss of one’s own child. Starting from these scales, each interview is classified in one of the primary attachment patterns: secure/autonomous, dismissing/avoidant, and preoccupied/entangled or “cannot classify.” Where applicable, the “unresolved” pattern with respect to loss, trauma, or abuse could be scored. Multiple scoring is allowed (e.g., F/DS). AAI validation rests on more than 25 years of developmental and clinical research ( van IJzendoorn and Bakermans-Kranenburg, 2008 ). Rigorous psychometric testing and meta-analyses of the AAI demonstrate its stability, and discriminant and predictive validity in both clinical and non-clinical populations. In a recent meta-analysis of 61 clinical samples ( van IJzendoorn and Bakermans-Kranenburg, 2008 ), strong associations were found between psychiatric diagnoses (i.e., anxiety disorders, borderline personality disorder) and attachment insecurity.

The Adult Attachment Projective Picture System ( George and West, 2001 ) is based on a standardized set of seven drawn pictures divided in Alone and Dyadic stimuli 4 . The pictures describe major attachment events, potential threat of separation, illness, solitude, death, and abuse. The stimuli are: child at window (window); departure; bench; bed; ambulance; cemetery; and child at corner (corner). Individuals are asked to make up a story for each image in which they describe what is going on in the picture, what led up to the scene, what the characters are thinking or feeling and what might happen next. The responses are audiotaped for transcription and verbatim analysis. The AAP assesses attachment in the Bowlby-Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ). The AAP Coding System, leads to four adult attachment classification patterns, – secure/autonomous, dismissing, preoccupied, unresolved – as they were traditionally assessed in the AAI, even if no multiple scoring is allowed. The AAP also assesses attachment personal elements that individuals may exclude from conscious awareness. Attachment classification using the AAP is determined by evaluating patterns of responses using a set of seven scales grouped under three major categories: discourse, content, and defensive processing. These dimensions evaluate the attachment story content related to the hypothetical characters portrayed in the stimuli, to defenses, and to self-other boundaries in narrative discourse ( George and West, 2001 , 2012 ). Discourse codes evaluate personal experience. Content codes include agency of self and connectedness for alone pictures, and Synchrony for dyadic pictures. Finally, the AAP codes for defensive exclusion, segregated systems, deactivation, and cognitive disconnection ( Bowlby, 1980 ). They represent different degrees of “protection” from dangerous distressful events. Segregated systems describe a mental state in which painful attachment-related memories are isolated and blocked from conscious thought and rooted in experiences of trauma or loss through death ( Bowlby, 1980 ). Deactivating defensive processes are defined as attempts to dismiss, cool off, or shift attention away from attachment events, individuals, or feelings in response to the picture stimuli. Cognitive disconnection processes literally disconnect the elements of attachment from their source, thus undermining consistency and the capability of holding in one’s mind a unitary view of events, emotions, and the individuals associated with them. The most recent review of AAP reliability and validity was published in George and West (2012) . AAP–AAI convergence for secure versus insecure classifications was 0.95 (κ = 0.75, p = 0.000); convergence for the four major attachment groups was 0.89 (κ = 0.84, p = 0.000; George and West, 2001 , 2012 ; West and George, 2002 ). The AAP has also been shown to be useful in studying the neurobiological and emotional expression correlates of attachment in non-clinical and clinical samples ( Buchheim and Benecke, 2007 ; Buchheim et al., 2007 , 2008 , 2009 ; Fraedrich et al., 2010 ) as well as in single case studies ( Lis et al., 2011 ).

Both AAI and AAP show individual strengths in measuring attachment patterns, but their combined use increments their overall usefulness. The AAI, the golden standard measure of adult attachment ( Bakermans-Kranenburg and van Ijzendoorn, 1993 ), focuses on the assessment of the representational model and coherence of mind, and assumes developmental continuity of the attachment system, evaluating abuse and loss in one’s personal history. The AAP, based on the Bowlby–Ainsworth tradition ( West and George, 2002 ; George and West, 2012 ), assesses current views of self, attachment figures, and expectations about the productiveness of attachment relationships, elucidating how current experience activates attachment accomplishment, disappointment, and trauma from the past ( West et al., 1995 ; George and West, 2012 ). The AAP is also more trauma sensitive and underscores defense patterns (e.g., Hesse, 2008 ; George and West, 2012 ). The combined use of the AAI and the AAP gives the chance to portray a complex image of the patient’s attachment pattern, providing a detailed narrative about life attachment activators such as separation, fear, solitude, and danger, shedding light on the unconscious defensive mechanisms and exploring the accessibility of attachment figures during the life-span (e.g., Hesse, 2008 ; George and West, 2012 ). The SCL-90-R contributed to get Matilde’s self-evaluation of symptoms.

Assessment Findings

Results from DSM-IV diagnosis, SCL-90-R and SWAP–200 during the assessment phases are described in Table 2 . Results from attachment tools are reported below and AAI subscales are shown in Tables 3 and 4 .

TABLE 2. Results from SCL-90-R and SWAP–200 in assessment phase.

TABLE 3. AAI experience scales.

TABLE 4. AAI state of mind scales.

Matilde’s AAI was scored F2/Ds3, secure with features of dismissing or some restriction in feelings of attachment (F2 = free somewhat dismissing or restricted in attachment; DS3 = dismissing restricted in feelings with some evidences of Lack of Memories; George and Solomon, 1996 ; see Tables 3 and 4 ). Matilde secure pattern was so defined because she was able to explore his or her thoughts and feelings about childhood experiences, with fresh speech, humor and forgiveness, without becoming angrily or passively overwhelmed while discussing them. Generally, Matilde appeared to be aware of the nature of experiences with her parents and of the effects of such experiences on her present state of mind and on her personality. Nevertheless, she remained a little bit restricted in her emotional expressions, preferring to rationalize. State of mind scales tapped a dismissing feature, showing a slight tendency to idealize parents and some lack of memories. Further information about Matilde derived from a qualitative analysis of the AAI. She did not report any severe illness, traumatic or abuse experience. However, separations caused her some distress, but she felt always supported and listened by her mother. She described herself as a very calm girl but, during early childhood, she was very shy and very worried about separation: “ I became very agitated when I did not see my parents, when they were not there, when they were away from home, ” “ Once we were at the lake. I was on the one side of the road and my parents were on the other side. Some people passed and so I could not see my parents anymore. I did not see them anymore and I began to scream .” However, she remembered that during her summer camp experience, when there were no well-known friends or schoolmates: “ I felt the distance from home, I felt lost and confused … I was very happy to go back home. The bus journey to go back home was very stressful,” “I do not like changes. I am worried about changes. ”

She described the relationship with her mother as: affectionate, playful, reciprocal, supportive, and protective. When she was asked to recall a specific example in respect with “supportive relationship” she reported that “ I gulped a small toy and it remained caught in my throat. I had to be taken to the hospital. I was very agitated, I screamed that I was frightened of dying. Mammy was very supporting … I mean comforting. ” She was able to identify a specific episode, but in a superficial and not qualitative consistent manner ( Grice’s qualitative maxim ): the adjective-descriptor (supportive) of relationship with her mother was supported with a second generalized positive descriptor (comforting). The adjectives she chose to describe the relationship with her father were: always affectionate, playful, formal ( “home rules had to be respected, for instance times for lunch and dinner” ), respectful ( “Nothing escaped from him; his words had always a weight” ), and important. Such aspects were more linked to father’s role as a parent and to school achievement: “I felt very bad about his criticism.” Matilde felt closer to her mother than to her father, from whom she felt more detached. Moreover, during school years she always felt a little bit anxious and agitated about school achievement and completion. Beside all these difficulties, she always felt supported and sustained by her mother, and at the end she demonstrated herself as very forgiving toward her father’s severity. When asked to imagine the possibility of being separated from her child, Matilde reported to feel “ a big void, a big feeling of lost, of mourning, a big pain, an absence of being complete ” and the three wishes about this child when he would be 20-years old were: “ to be able to choose, to have a clear reasoning, not being confused, and to be able to be autonomous. ”

Matilde was judged as secure on the AAP (F): she showed, at the representational level, a flexible and organized thinking about attachment situations and relationships ( Bowlby, 1969/1982 ). She was confident that she could rely on attachment figures to achieve care, safety and protection and, when alone, she could access internalized attachment relationships ( George and Solomon, 1996 , 1999 ). In response to two of the alone stimuli – Window and Cemetery- as a secure individual, she demonstrated the ability to think (i.e., Internalized Secure Base) and to take constructive action. She also used flexible defensive processes to integrate attachment feelings and events. Using these resources she was able to re-organize her attachment-related feelings, also in the few cases (Bed and Cemetery Stories) when she became disorganized by feelings of loss and danger. From the pattern of story responses it appears that Matilde, above all other response qualities, genuinely valued and represented the capacity for integration of self and relationships. The responses to the Alone pictures demonstrated Matilde’s internal resources, such as the potential availability and responsiveness of attachment figures. As a representative example of this attitude the Cemetery picture (a man stands by a gravesite headstone) story is reported.

“A gentleman who had a bad day or felt sad or depressed or undervalued because of an episode that happened during the day and goes and visits his father … he feels reassured because he found a place where to think about his life by himself and then he will go back home and will be able to reconsider what happened from a different point of view.”

In Cemetery, Matilde reveals the intensity of feelings of pain associated with loss: she tries to deal with them through some form of uncertainty and desire to withdraw (cognitive disconnection). These forms of organized defensive mechanisms keep Matilde’s attachment system activated but they cannot prevent her from becoming dysregulated, as evidenced by painful attachment-related feelings of loss represented by the appearance of a them where no clear distinction is made between life and death (“he goes and visit his father”). A segregated system (spectral domain) was activated by the picture features, which portray a man visiting a grave. However, Matilde was able to depict the man as engaged in some kind of “thinking.” The man is able to “reconsider what happened from a different point of view.” This process belongs to Internalized Secure Base, and portrays Matilde’s ability to clearly differentiate between the living and the dead. The Dyadic picture stimuli portray attachment-caregiving dyads. The responses to Dyadic picture stimuli demonstrate Matilde’s representation of the self and other in attachment situations when attachment figures are present and accessible, but they also demonstrate the use of attachment figures to quell the attachment anxiety aroused in the scenes depicted in the cards. Bed picture (a child and woman sit opposite to each other on the child’s bed) could be a representative example.

“A boy had a nightmare during the night and his mother woke up eh … now he is scared and he would like to be close to his mum … the mum is trying to soothe him and she will be able to do it … the boy will come back to sleep quietly … (Anything else?) no.. maybe the bad dream was … was about the fact of staying alone without his mom … and now … he wants his mom first!”

In Matilde’s story, the child signals his attachment need after a “nightmare” (segregated system in AAP) and the mother is able to provide a contingent and soothing answer, containing the potential breakdown of the attachment system and resolving the segregated system. Both AAI and AAP classified Matilde as secure with somewhat dismissing or restricted feelings in attachment without elements of unresolved abuse or trauma. However, both tools detected some shortcomings about fears of separation and danger. The AAI was not able to draw attention in an exhaustive way to how Matilde experienced abandonment fears and felt scared without the presence of her parents. Instead the AAP clearly depicted this nuance, under a secure pattern, showing that her attachment was threatened by painful attachment-related feelings of loss, and by a nightmare (in Bed picture), a signal of danger. In both tools she demonstrated her ability to re-organize herself, but these disturbing feelings kept being alive underneath her reorganized secure pattern.

Case Formulation Based on PDM Axes

S -axis – Matilde had a diagnosis of DSM-IV ( American Psychiatric Association [APA], 1994 ), and showed a slightly High Functioning profile with Obsessive, Schizoid-Avoidant and Dysphoric characteristics, in both PD and Q factors in SWAP–200. Matilde’s SCL-90-R symptom profile revealed depression, anxiety, obsessive–compulsive, and somatization scores in the clinical range (Table 2 ).

M -axis – this Axis describes nine dimensions, which systematize the capacities that contribute to an individual’s personality and overall level of psychological health or pathology.

Capacity for regulation, attention, and learning

In the clinical interview, she said, “ I lost control of my body and thinking. ” She appeared in a profound state of crisis and she appeared to be unable to cope with it and with connected feelings of anxiety and distress. She (a) adhered rigidly to daily routines and became anxious or uncomfortable when they were altered, (b) had trouble making decisions and was indecisive or vacillated when faced with choices, (c) was overly concerned with rules, procedures, order, organization, and schedules: all obsessive strategies which would interfere with processes that support attention and learning from experience. However, according to Bowlby, being secure at both AAI and AAP means that Matilde had basic capacities for regulation. Matilde appeared to believe in the seeking of proximity and support as effective ways in regulating distress, in particular in AAP Dyadic pictures. However, at the moment of assessment, she was not able to recur to her internalized security patterns, showing how an emotional regressive crisis was rising up. Although Matilde subjectively felt unable to cope with it and was very frightened by it, according to the AAP and AAI, the dysregulation appeared momentary and not prolonged. It seems she was still functioning as she described herself in the early childhood memory, when she could not see her parents and she got anxious at the thought of being lost. However, her basic secure attachment suggests that, thanks to the therapy, she could re-establish her capacity of self-regulation, a secure person’s basic characteristic.

Capacity for interpersonal relationships

Although she was excessively devoted to work and productivity, compromising leisure and relationships, her secure attachment pattern at the AAI and AAP indicated that Matilde had a positive representation of available adults who can offer protection, support, care, and comfort in threatening and stressful situations. The AAP supported also her potential ability to be connected with other relational systems such as partners and peers, almost in a concrete manner, since she was able to tell stories in which she described specific connections with friends and other people in general. However, her agency, connectedness, and synchrony were at the moment “quite silent” in her everyday life. She needed help to regain these resources.

Quality of internal experiences

In AAI and AAP she felt reassured by (her) mother’s proximity, soothing, and comfort. However, episode and story plots clearly indicated some separation anxieties and worries in respect to changes, which she faced using dismissing defense mechanisms. AAP clearly depicted how under a secure pattern, her attachment was threatened by painful attachment-related feelings of loss and danger. Until that moment, such feelings were isolated and blocked from conscious thought. Even if she was able to deal with these experiences in childhood thanks to her mother’s comfort, her fear of loss connected to the fear of being alone and unprotected seem to re-emerge We hypothesized that she was having trouble in coping with new adolescence-through-young adulthood tasks, such as the adult separation-individuation process. According to the SWAP–200, she experienced a sense of personal dissatisfaction, poor self-regard, low self-esteem, lack of confidence, and chronic self-criticism. Her unrealistically high standards together with her expectation of being “perfect” above all in her achievements, made her feel guilty, depressed and despondent, with negative self-regard toward others, and the world at large.

Affective experience, expression, and communication

According to the SWAP–200, Matilde tended to defend herself via the inhibition of emotion expression, by means of abstract thinking and intellectualized terms, and appeared unable to recognize her wishes and impulses. Apparently, intellectualization and disavowal defenses (above all rationalization) led her to the avoidance of expressed conflict and emotions – both positive and painful. This emotional constriction resulted in a bottled up affect being channeled into panic attacks. The SWAP–200 stressed the risk of recurrent episodes of overt anxiety, tension, nervousness, and irritability and difficulty in acknowledging or expressing underlying feelings of anger and resentment. The AAP and AAI confirmed that underneath this block of affection there was a rich and positive affective state she had internalized during childhood life experiences. However, although not so rigid, her present affective state of constriction and inhibition was consistent with the rigid attempt to neutralize affect using deactivating defenses in the AAP. The emotions, which were bottled up in the segregated system, surely carried a negative and overwhelming emotional tone, which at the moment she was unable to deal with.

Defensive patterns and capacities

The SWAP–200 indicated the extent to which Matilde tended to defend her from expressing emotions, by abstract thinking and intellectualized terms. Although her defenses were at a mature-neurotic level, they were not solid enough to allow her to avoid the recourse to symptoms and anxiety. From an attachment viewpoint-AAP-Matilde shows a different picture underneath. Here defenses appeared organized and flexible, but in order to keep a regulated attachment she relied more on deactivation than on cognitive disconnection ( George and West, 2012 ).

Capacity to form internal representations

Matilde was able to form internal representations of self and others, and her experiences were symbolized mentally. However, in the current state of distress, some emotions and conflicts were expressed somatically through her somatic symptoms and panic attack episodes.

Capacity for differentiation and integration (ego strength, self-cohesion, stability of reality testing). Overall, her AAP stories and her narrative in the AAI revealed that she was able to look realistically at herself, people, and relationships. Also during the clinical interview, a solid, stable and good child image emerged, but was not integrated with an adolescent and adult image: Matilde’s ego was fragile and was shattered by a large number of symptoms, her self-image was damaged and not well integrated; moreover, she looked younger than her age and never talked about sexuality or intimate relationships.

Self-observing capacities

Matilde did not demonstrate good self-observation capacities. Her level of current distress, extension of intellectualization and rationalization defenses, avoidant and constricted emotional style did not allow for an adult and mature emotional insight.

Capacity to construct or use internal standards and ideals. SWAP–200 showed how she currently set unrealistically and childish high standards for herself and how she appeared intolerant of her own human defects.

Therapeutic Stance and Therapy Guiding Conception

Matilde looked younger than her age and did not talk about sexuality or intimate relationships and we supposed that she did not undergo a true adolescent process. Looking at her secure attachment pattern, the therapist hypothesized that the present state of dysregulation and symptomatic picture is transitory and derived from the new young adulthood tasks she has now to deal with during her transition toward adulthood, such as moving to University. From a psychoanalytic as well as an attachment-oriented viewpoint, we hypothesized she was not able to face adolescent and adult separation-individuation processes. According to attachment theory, attachment relationships foster integration of attachment with relationships in peer behavioral systems during adolescence and adulthood: these include friendships and romantic relationships ( West and George, 1999 ; Allen, 2008 ; George and Solomon, 2008 ; George and West, 2012 ). Psychoanalytic theories also agree that the individual needs to face adolescence as a separation-individuation process, where adolescents need to acquire an individual separate self-identity through identification with parents and separation from childhood ties. The AAP and AAI were taken into account, making the therapist sensible to specific topics concerning separation, loss, and loneliness, able to reactivate and unleash childhood attachment-related memories of fear of being lost and completely alone during treatment itself. Matilde needed to explore this topic with a therapist who would represent for her, in the transference, a secure parent similar to the one she had already experienced in her life via her mother’s supporting stance. In particular, the therapist expected that supportive psychotherapy would integrate the “segregated” themes locked in Matilde’s experience: she might then be able to consciously accept and deal with her blocked emotions and affects, as to regainenjoyment of life and satisfaction in the relationship with significant figures, re-finding the haven of safety of self and others that she had experienced in her childhood.

The clinical case formulation suggested for Matilde a therapeutic approach in the context of a “partial rapprochement” between attachment theory and psychoanalytic individual psychotherapies as the best solution ( Skean, 2005 ; Slade, 2008 ; Steele et al., 2009 ). This intervention would include: (a) The use of therapeutic relationship and alliance as vehicles for a “secure base” constitution, in order to observe and understand the client’s interpersonal behavior ( Spence, 1982 ; Binder et al., 1987 ; Dozier et al., 1994 ; Slade, 2008 ; Steele et al., 2009 ); (b) Relationships with the self and others (internal and external), in terms of personality functioning but also from client’s transference and therapist’s counter-transference points of view of ( McWilliams, 1999 ; Skean, 2005 ); moreover, patient’s real or transferential relationships and past-present pattern of emotional responses and behaviors were examined ( Gabbard, 2009 ). However, a particular emphasis was put on the supportive versus insight-oriented modes of therapy ( Skean, 2005 ), because Matilde needed: (a) to reduce physical and psychical symptoms ( S-Axis ; Gabbard, 2009 ), and reestablish a consistent level of functioning ( Dewald, 1971 ; Ursano and Silberman, 1996 ; Douglas, 2008 ); (b) to strengthen her fragile ego. Her defenses were at a mature-neurotic level, but were not solid enough to stop the recourse to symptoms and anxiety ( PDM: Defenses; Capacity for Differentiation and Integration ), (c) to change her self-definition, improving self-esteem, and getting a more integrated perception of the self, ( PDM: Qualiy of internal experiences; Capacity for Differentiation and Integration ); (d) To function better in everyday life investing lessin achievements and study matters ( Dewald, 1971 ; Ursano and Silberman, 1996 ; PDM: Rehabilitation ); (e) to improve her coping skills and to learn consistent strategies to manage her painful internalized feelings ( PDM: Capacity for regulation, attention, and learning ); (f) to increase her capacity to express affects both on the positive and negative aspects evidenced by AAI and that were consciously often inhibited and not acknowledged (PDM: Affective Experience, Expression, and Communication) ; (g) to encourage more consistent ways of relating to others ( PDM: Capacity for Intepersonal Relationships; Misch, 2000 ). In addition, her concrete and intellectualized thinking (SWAP–200) made also difficult for her to deal with interpretations, suggesting again the need of a more supportive approach.

Brief Outline of the Therapy Unfolding

As expected, during the first months of therapy Matilde showed a high symptomatic picture. She appeared very distressed and confused, with a sense of failure, of inability to reach her standards. Long boring and intellectualized descriptions of daily routines and of University achievement, anxiety, uncertainties and doubts about her achievements were her main topics. The therapist acted as a secure attachment figure ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ), as a caregiver who offered security and soothing to Matilde’s distress. She worked actively helping Matilde to contain anxiety, shame, and anger ( Winston et al., 2004 ). The therapist, very slowly and respecting her defenses, tried to reduce Matilde’s anxiety, to increase her self-esteem and hope, and to make her more aware about herself as a person, and not only as a student who had to achieve some standards. She begun anyway to talk about how she could count on her mother, the only person that always helped her when she felt anxious and distressed. This finally opened a window on her family and her separation difficulties during childhood, and she started to tellhow she felt alone and how much she needed her mother’s soothing, how much difficult it was to face her first experience of a 2-week summer camp, as well as to begin elementary school, middle school, and high school. She also admitted that anyway with her mother’s help she was able to face these separations. She began to recognize, following therapist’s verbalizations, that at that time she was beginning a new kind of “school-experience,” similarly to the situation at present. In parallel with this initial understanding of her fear of facing changes and separation, all symptoms increased, especially anxiety symptoms. “ It is a nightmare ” were her words. She told the therapist that she called mommy every morning and evening but it was not enough. She felt lost and alone. The episodes reported by Matilde at this phase of the therapy were very similar to the ones she reported in the AAI, and the ways she dealt with the present separation from her mother were similar to the ones she previously used during her childhood: going concretely to her mother to be soothed and supported. Moreover, she used the same words she previously used in the two AAP stories where segregated systems were unleashed but resolved. It could be hypothesized that in the transference with the therapist Matilde’s attachment system was activated and “seen in action” ( George and West, 2012 ). As she said during the AAI, it was always difficult for her to deal with changes. Now in the transference with the therapist she was reliving her fears, the same fears she experiencedin childhood, the ones that were unleashed at the beginning of the University andthat she was able to face only through anxiety and obsessive symptoms. It was difficult for her to connect this experience with the new separation experience from home and from herself as a child, now that she had to face University and all the complex processes connected with entering adulthood. In the transference with the therapist she was reviving an acute separation anxiety and she was also unconsciously angry at the therapist’s impossibility to help her. The therapist tried unsuccessfully to interpret and to connect this profound regression with Matilde’s previous separation anxieties. Words were not useful. Wallin (2007) supports that “ what patients are unable to explain with words, tends to be evocated, enacted or incorporated ” ( Zaccagnini and Zavattini, 2009 ). The working alliance showed for the first time some ruptures, and the risk of treatment disruption itself became a subject of discussion ( Appelbaum, 2005 ; Colli and Lingiardi, 2009 ). Matilde’s alliance rupture style was characterized by the presence of withdrawal maneuvers: emotional disengagement from the therapist, skipping from topic to topic, responding in an overly intellectualized fashion, and very short answers ( Safran and Muran, 2000 ). In such a moment of regression, she really needed a concrete comfort and physical contact with her mother. The therapeutic stance was not enough for her; she decided that the best way to deal with the situation was to go back home. Matilde went home, “ to be near to her family. ” Coming back to her parents represented for her the haven of safety she described in her AAP. Parents were still used as attachment figures during early, middle and late adolescence and also during young adulthood ( Fraley and Davis, 1997 ), especially under conditions of extreme stress ( Huntsinger and Luecken, 2004 ; Kamkar et al., 2012 ). She stayed home with her family for 3 weeks. When she came back, she appeared less anxious and more integrated: little by little, Matilde was more able to feel the setting as a place where exploration of her personal life and new experiences could be initiated, shared, and enjoyed. She was able to develop positive feelings toward the therapist ( Misch, 2000 ). She began to integrate positive and negative feelings in life events, becoming more and more flexible, increasing her ability to tolerate changes and learning to find new solutions to life schedule. She reached some goals toward adulthood and began to find real friends, also far from home, and to spend energy in different activities (e.g., organization, church, neighborhood, etc.). She loved challenges and she felt pleasure in realizing her goals and in pursuing long-term ambitions. A boyfriend appeared. The symptoms disappeared. She continued to use a great amount of razionalization in order to explain some affective aspect of her experiences. from the point of view of attachment, she mantained a tendency to change the topic when she approached emotional issues using displacement defenses in order not to deal with her core difficulties. The therapeutic goal of accomplishing a true adolescent process was also achieved. A solid and good child image was now more integrated with an adolescent and adult image. Some developmental tasks were reached on the way toward adultood (friendship and romantic relationship). The therapist discussed with Matilde the fact that some shortcomings were still present in her personality functioning, but both agreed that she wished now to try to go on with her life by herself. As Freud (1966) suggested, the aim of psychotherapy at a developmental age is to help the patient to proceed along his or her developmental lines. Now Matilde managed to integrate some issues concerning the developmental step of adolescence and young adulthood and she wished to try new experiences by herself.

Follow-Up Findings

Results from DSM-IV diagnosis, SCL-90-R, and SWAP–200 in the follow-up phase are described in Table 5 .

TABLE 5. Results from SCL-90-R and SWAP–200 in follow-up phase.

The AAP was scored secure, but without any segregated systems. As a representative example of some new attitudes, Matilde’s stories for Window and Departure pictures are reported.

Window (a child looks out a window): a girl who woke up eh … parents are not there, they are at work and she knows she is alone at home. She is quiet. She is looking out of the window thinking about her mom and the fact she will come back home in the afternoon. She is thinking about who she can invite in … who can … can keep … her company. She is quiet, excited by the day without parents (What might happen next?) she will find someone … a … a friend … a neighbor … finally she will have fun (Anything else?) No.

Matilde tells one of the most common AAP stories for the Window picture: a typical home-related scenario in which a little girl needs to manage her solitude. The girl is “ quiet ” although she is alone home. So, Matilde is not threatened by the girl’s loneliness, but she is somehow able to enjoy the possibility of being alone. The absence of segregated systems demonstrates the absence of dysregulating events, which could have led to her being alone (her parents are just working) and of girl’s traumatic reactions. More specifically, the girl is depicted “ thinking about her mom, ” activating her ability to internalize the secure base and being “ content in solitude. ” In fact, this connection with the thought of her mother’s coming back in the afternoon keeps the girl regulated and lets her also think about something specific to do alone: “ she looks out of the window thinking about who she can invite in … who can keep … her company. ” The little girl can recall the affiliative system (“ friend ”) to handle her loneliness. Her ability to think makes Matilde confident and envisages the possibility of changing things in the immediate future (“ she invited friends ”). From a developmental point of view, Matilde is now a late adolescent-young adult: she is prone to consider also peers and friends as a secure base to refer to in moderately distressful situations.

Departure (an adult man and woman stand facing each other with suitcases positioned nearby): a woman is going to leave for a business trip and she is saying goodbye to her husband … he took her to the station … she was already planning what she needed to do during the trip … yes during this period of work … he is quiet and he thinks about their relationship, about how they enjoy to be together, what he would do without … in these few days without his wife…however … she will leave and he will spend a few dull days … (Anything else?) No.

In Departure, Matilde is able to tell a typical AAP story, which portrays a couple at the train station. The husband thinks about their relationship and he feels that his days will be dull without his wife. Matilde’s story suggests togetherness and a goal-corrected partnership. She portrays the husband as involved in a contingent, reciprocal and mutually engaging relationship.

Qualitative Clinical Evaluation at the End of Therapy

Matilde did not have any DSM-IV diagnosis in Axis I and her personality functioning resulted carachterized by obsessive high functioning features (PDM S -axes, SWAP–200). She had no more panic attacks accompanied by strong physical arousal, and her experiences were now more mentally symbolized. Her SCL-90-R final symptom profile revealed a magnitude within the normal range. Only two symptomatic distress levels, obsessive–compulsive, and anxiety, still penetrated the clinical range, but their intensity had diminished compared to the assessment phase.

Her self-image improved: she now experienced a sense of personal satisfaction, sufficient self-esteem and self-confidence (PDM M -axes). The “negative-stressful” components of her affective world were still present but the level of self-blame, and emotional constriction greatly diminished. She was now less inhibited and became more spontaneous in expressing emotions, and also anger. Matilde still showed a pattern of Mature-Neurotic defenses and an absence of primitive defenses. Rationalization, intellectualization, undoing, and displacement were the mostly used defenses, but were now more flexible, less pervasive and she was able to avoid recourring to symptoms and anxiety. The AAP confirmed a flexible use of defenses and reduction in thereliance on dectivation defenses; however, her kind of defense structure still did not allow neither an emotional insight about her motivations and behaviors, or psychological mindedness.

Matilde remained secure in her attachment pattern, changing her defensive approach through a more integrated and coherent one, in which no more segregated systems or disregulation were present: she was now able to use again her self-regulation capacities autonomously (PDM M -axes). Her attachment adolescent crisis was resolved; she was out of her “nightmare.” She still seemed naïve and used an excessive part of her mental energy to keep emotions and feelings at bay, showing a limited ability to appreciate metaphor, analogy, or nuance. In the context of a supportive stance, comprising a secure and holding environment and an atmosphere based on emotional safety, she was able to work on her fear of loss and changes allowing her internalized attachment status to reach an adult structure. She was now able to deal with adult tasks using her internalized parental figures, thinking about how they could protect her. Matilde now found pleasure, satisfaction, and enjoyment in everyday-life activities. Her underneath security pattern now re-emerged allowing her to maintain a loving relationship, and to engage and keep long-standing and intimate friendships and relationships (PDM M -axes). She now set less unrealistically high personal standards and she was now able to find meaning in belonging and contributing to a wider community (e.g., organization, church, neighborhood, etc.). Table 6 shows Matilde’s qualitative picture at baseline and at follow up.

TABLE 6. Qualitative Matilde’s picture of features at baseline and at the end of psychotherapy.

This clinical case study highlighted the importance of assessing patient’s idiographic and intra-subjective features ( Hilliard, 1993 ). The nature of the clinical case perspective requires a rich diagnostic process that includes both a nosographic approach (such as DSM-IV) and a more multifaceted point of view to assess the specific patient’s psychological functioning ( Barron, 1998 ; Shedler and Westen, 2007 ). There have been few studies investigating the psychotherapy process in supportive therapies ( Orlinsky et al., 2004 ), and very few studies were devoted to inserting also the contribution of validated measures of attachment. Slade (2008) endorsed that, although attachment theory terms have been incorporated in the present psychoanalytic theory, only few therapists have really integrated core elements of the attachment perspective in their clinical thought. Above all, few of them inserted measures of attachment and their strategies to understand the therapy unfolding ( Rockland, 1989 ; Porcerelli et al., 2011 ). Assessing attachment means more than just determining a patient’s attachment classification status. The benefit from the inclusion of attachment assessment to a multi-method approach is the chance of using results to elucidate the patient’s representational and defensive patterns related to attachment activation ( Bowlby, 1980 ).

This paper tried to illustrate a clinical case where results from attachment tools together with PDM assessment could help to give a more integrate picture and to form and inform the unfolding of the therapy. The incremented validity about symptoms and attachment internal working models evaluation added a specific qualitative contribution to each tool (e.g., SCL-90-R gave the self perception of symptomatology and SWAP–200 the clinical perception of it; AAI and AAP increased biographical information and defense mechanism, respectively). The paper presented a case formulation in which a psychodynamic approach was integrated with an attachment theory framework both in the assessment and post-assessment phases and with a “ supportive psychotherapy approach. ” The secure attachment status, as derived from the AAI and the AAP, helped to structure Matilde’s therapy, adding information to the therapeutic intervention: Matilde’s secure attachment resulted helpful to establish a therapeutic plan, to facilitate the therapeutic alliance and the answer to the therapy, and to help her to face her symptoms and internal difficulties ( Douglas, 2008 ; Steele and Steele, 2008 ). The AAP and AAI were taken into account, making the therapist sensible to the specific topics concerning separation and loss, which were reactivated throughout treatment. Matilde needed to explore them in the context of a “ safe haven, ” the same context she had previously experienced in her life with her mother’s supporting stance. On her side, the therapist recreated and maintained a well knownholding environment, affective mirroring and personal warmth ( Markowitz, 2008 ) and an atmosphere based on emotional safety ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). She provided Matilde with the secure base she temporary lost, a starting point from where the exploration of painful experiences in her present life could finally begin. This gave her the possibility to recall some hidden memories, leading to self-exploration ( Parish and Eagle, 2003 ; Mallinckrodt et al., 2005 ; Holmes, 2010 ). The “supportive approach” and the role of attachment framework turned out to be a key factor in the assessment and in the development of an effective therapeutic relationship with Matilde. Within a psychoanalytic framework, through the unfolding relationship with the therapist, Matilde brought her interpersonal world into the treatment room and allowed the therapist to experience aspects of her structuring of reality ( Crits-Christoph and Connolly, 1999 ; Skean, 2005 ). The conclusion of the therapy showed a more integrated picture, where symptoms were no more outstanding and Matilde seemed to be out of her big “nightmare” and ready to face her life tasks in a more integrated and young-adult way. The post-treatment AAP confirmed that Matilde was able to integrate these issues of separation and loss. She was a very defensive neurotic patient blocked at latency, and showed some shortcomings related to the separation-individuation process ( Mahler et al., 1975 ) both from a psychoanalytic and from an attachment point of view.

The treatment helped Matilde to make a developmental step toward maturity: “from childish features to adolescent ones, reaching the capacity of (emotionally) exploring the possibility of living independently from parents (…) because they know that they can turn to parents in case of real need” ( Allen and Land, 1999 , p. 322). The therapist was both an “attachment figure” that helped Matilde to face new experiences, as well as a transference object ( Dozier et al., 1994 ). Matilde’s development resulted in increased abilities in managing the goal-corrected partnership with each parent, in which behavior is not determined only by adolescent’s current needs and wishes, but also by recognition of the need to manage certain set goals for the partnership ( Bowlby, 1973 ).

As all clinical case studies, this study suffered from some limitations ( Hodkinson and Hodkinson, 2001 ): results are not generalizable in the conventional sense; it looks expensive, if attempted on a large scale and the complexity examined is difficult to represent simply and briefly. Furthermore, clinical case studies results stronger when researchers’ expertise and intuition are maximized, but this raises doubts about their “objectivity”: this type of research is easily subjected to criticisms by those who do not like the messages that they contain; and finally it cannot answer a large number of relevant and appropriate research questions that future studies could address (e.g., in this sense, it could be highly valuable for future research to compare PAD patients with different attachment styles). However, this particular case study could be considered an original and extremely valuable one, because it is grounded in “lived reality.” This helps us to understand complex inter-relationships between diagnosis, measures and their clinical application, facilitating the development of conceptual/theoretical issues and the exploration of unexpected and unusual situations, such as PAD in a secure attached patient. As regards the choice of this patient, the present paper can provide “provisional truths, in a Popperian sense” ( Hodkinson and Hodkinson, 2001 ): it represents the best account of such assessment and treatment in the current literature, and it should stand, until contradictory findings or better theories are developed.

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

• ^ The PDM was developed to describe “the depth as well as the surface of emotional, cognitive, and social patterns” (p. 1) of an individual’s functioning, as to improve the diagnosis and treatment of psychological disorders. PDM comprises three areas: personality patterns (Axis P ), mental functioning ( M -axis), and symptoms ( S -axis). Our attention focused mainly on mental functioning or M -axis, “a microscopic look at mental life” (p. 8), although some attention was paid to symptoms and concerns or S -axis.
• ^ The patient self-referred to a psychodynamic service, where therapists are trained to use an Operationalized Psychodynamic Diagnosis approach during consultation sessions, preferring free or “per area” clinical sessions to interviews (e.g., SCID).
• ^ The self report SCL-90-R was digitally computed. Inter-reliability reached Cohen’s k = 1 for AAI and AAPs final classifications; 0.93 for AAI subscales; 0.85 for AAP codings; 0.72 for SWAP–200 final scales.
• ^ (1) Neutral (children playing ball); (2) child at window (alone); (3) departure (dyad); (4) bench (alone); (5) bed (dyad); (6) ambulance (dyad); (7) cemetery (alone); (8) child in corner (alone).

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Westen, D., and Shedler, J. (1999b). Revising and assessing Axis II: II. Toward an empirically based and clinically useful classification of personality disorderds. Am. J. Psychiatry 156, 273–285.

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Zaccagnini, C., and Zavattini, G. C. (2009). Introduzione a D. J. Wallin, Psicoterapia e Teoria dell’Attaccamento. Bologna, Il Mulino, 7–21.

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Keywords : assessment, attachment, psychodynamic supportive therapy, outcome research, clinical case study

Citation: Salcuni S, Di Riso D and Lis A (2014) “A child’s nightmare. Mum comes and comforts her child.” Attachment evaluation as a guide in the assessment and treatment in a clinical case study. Front. Psychol. 5 :912. doi: 10.3389/fpsyg.2014.00912

Received: 21 May 2014; Accepted: 30 July 2014; Published online: 20 August 2014.

Reviewed by:

Copyright © 2014 Salcuni, Di Riso and Lis. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Silvia Salcuni, Department of Developmental and Socialization Psychology, University of Padua, via Venezia 12, 35100 Padova, Italy e-mail: [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Case Studies in Abnormal Child and Adolescent Psychology

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Il testo presenta dei casi che sono ben costruiti; le domande (e il corredo di risposte, altrettanto adeguate) tuttavia sono molto specifiche per gli studenti del corso che tengo e che diventeranno principalmente "social workers"; dunque non sono chiamati ad avere una competenza diagnostica così profonda

• Case studies based on real children provide realistic examples for students to pair with chapter readings.
• Short case studies modeled after DSM-5 clinical cases provide flexibility for instructors to assign these as in- or out-of-class assignments.
• Discussion questions paired with each case provide opportunities for critical thinking and analysis.

Sample Materials & Chapters

Chapter 1: The Science and Practice of Abnormal Child Psychology

Chapter 2: The Causes of Childhood Disorders

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

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Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

 Famous Case Studies

• Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
• Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
• Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
• Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
• Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

• Studying the effectiveness of psychotherapy approaches with an individual patient
• Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
• Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

• Studying psychological development from birth through adolescence
• Cases of learning disabilities, autism spectrum disorders, ADHD
• Effects of trauma, abuse, deprivation on development

Types of Case Studies

• Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
• Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
• Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
• Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
• Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
• Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

• Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
• Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
• Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

• News/Media – News coverage of events related to the case study.
• Academic articles – Journal articles, dissertations etc. that discuss the case.
• Government reports – Official data and records related to the case context.
• Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

• Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
• Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
• School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

• Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
• Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

• Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
• Include client demographics like age and gender, information about social relationships, and mental health history.
• Describe all physical, emotional, and/or sensory symptoms reported by the client.
• Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
• Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
• Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

• Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
• Present the results of the intervention,including any quantitative or qualitative data collected.
• For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

• Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
• Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
• Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
• Offer clinical implications, and suggest future research directions.

5. Additional Items

• Thank specific assistants for writing support only. No patient acknowledgments.
• References should directly support any key claims or quotes included.
• Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
• Provides detailed (rich qualitative) information.
• Provides insight for further research.
• Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

• Lacking scientific rigor and providing little basis for generalization of results to the wider population.
• Researchers’ own subjective feelings may influence the case study (researcher bias).
• Difficult to replicate.
• Time-consuming and expensive.
• The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895).  Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head.  Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868).  Recovery from the Passage of an Iron Bar through the Head .  Publications of the Massachusetts Medical Society. 2  (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972).  Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

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The Story of Genie Wiley

What her tragic story revealed about language and development

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

Emily is a board-certified science editor who has worked with top digital publishing brands like Voices for Biodiversity, Study.com, GoodTherapy, Vox, and Verywell.

Who Was Genie Wiley?

Why was the genie wiley case so famous, did genie learn to speak, ethical concerns.

While there have been a number of cases of feral children raised in social isolation with little or no human contact, few have captured public and scientific attention, like that of Genie Wiley.

Genie spent almost her entire childhood locked in a bedroom, isolated, and abused for over a decade. Her case was one of the first to put the critical period theory to the test. Could a child reared in utter deprivation and isolation develop language? Could a nurturing environment make up for a horrifying past?

In order to understand Genie's story, it is important to look at what is known about her early life, the discovery of the abuse she had endured, and the subsequent efforts to treat and study her.

Early Life (1957-1970)

Genie's life prior to her discovery was one of utter deprivation. She spent most of her days tied naked to a potty chair, only able to move her hands and feet. When she made noise, her father would beat her. The rare times her father did interact with her, it was to bark or growl. Genie Wiley's brother, who was five years older than Genie, also suffered abuse under their father.

Discovery and Study (1970-1975)

Genie's story came to light on November 4, 1970, in Los Angeles, California. A social worker discovered the 13-year old girl after her mother sought out services for her own health. The social worker soon discovered that the girl had been confined to a small room, and an investigation by authorities quickly revealed that the child had spent most of her life in this room, often tied to a potty chair.

A Genie Wiley documentary was made in 1997 called "Secrets of the Wild Child." In it, Susan Curtiss, PhD, a linguist and researcher who worked with Genie, explained that the name Genie was used in case files to protect the girl's identity and privacy.

The case name is Genie. This is not the person's real name, but when we think about what a genie is, a genie is a creature that comes out of a bottle or whatever but emerges into human society past childhood. We assume that it really isn't a creature that had a human childhood.

Both parents were charged with abuse , but Genie's father died by suicide the day before he was due to appear in court, leaving behind a note stating that "the world will never understand."

The story of Genie's case soon spread, drawing attention from both the public and the scientific community. The case was important, said psycholinguist and author Harlan Lane, PhD, because "our morality doesn’t allow us to conduct deprivation experiments with human beings; these unfortunate people are all we have to go on."

With so much interest in her case, the question became what should be done to help her. A team of psychologists and language experts began the process of rehabilitating Genie.

The National Institute of Mental Health (NIMH) provided funding for scientific research on Genie’s case. Psychologist David Rigler, PhD, was part of the "Genie team" and he explained the process.

I think everybody who came in contact with her was attracted to her. She had a quality of somehow connecting with people, which developed more and more but was present, really, from the start. She had a way of reaching out without saying anything, but just somehow by the kind of look in her eyes, and people wanted to do things for her.

Genie's rehabilitation team also included graduate student Susan Curtiss and psychologist James Kent. Upon her initial arrival at UCLA, Genie weighed just 59 pounds and moved with a strange "bunny walk." She often spat and was unable to straighten her arms and legs. Silent, incontinent, and unable to chew, she initially seemed only able to recognize her own name and the word "sorry."

After assessing Genie's emotional and cognitive abilities, Kent described her as "the most profoundly damaged child I've ever seen … Genie's life is a wasteland." Her silence and inability to use language made it difficult to assess her mental abilities, but on tests, she scored at about the level of a 1-year-old.

Genie Wiley's Rehabilitation and the Forbidden Experiment

She soon began to rapidly progress in specific areas, quickly learning how to use the toilet and dress herself. Over the next few months, she began to experience more developmental progress but remained poor in areas such as language. She enjoyed going out on day trips outside of the hospital and explored her new environment with an intensity that amazed her caregivers and strangers alike.

Curtiss suggested that Genie had a strong ability to communicate nonverbally , often receiving gifts from total strangers who seemed to understand the young girl's powerful need to explore the world around her.

Psychiatrist Jay Shurley, MD, helped assess Genie after she was first discovered, and he noted that since situations like hers were so rare, she quickly became the center of a battle between the researchers involved in her case. Arguments over the research and the course of her treatment soon erupted. Genie occasionally spent the night at the home of Jean Butler, one of her teachers.

After an outbreak of measles, Genie was quarantined at her teacher's home. Butler soon became protective and began restricting access to Genie. Other members of the team felt that Butler's goal was to become famous from the case, at one point claiming that Butler had called herself the next Anne Sullivan, the teacher famous for helping Helen Keller learn to communicate.  

Genie was partially treated like an asset and an opportunity for recognition, significantly interfering with their roles, and the researchers fought with each other for access to their perceived power source.

Eventually, Genie was removed from Butler's care and went to live in the home of psychologist David Rigler, where she remained for the next four years. Despite some difficulties, she appeared to do well in the Rigler household. She enjoyed listening to classical music on the piano and loved to draw, often finding it easier to communicate through drawing than through other methods.

After Genie was discovered, a group of researchers began the process of rehabilitation. However, this work also coincided with research to study her ability to acquire and use language. These two interests led to conflicts in her treatment and between the researchers and therapists working on her case.

State Custody (1975-Present)

NIMH withdrew funding in 1974, due to the lack of scientific findings. Linguist Susan Curtiss had found that while Genie could use words, she could not produce grammar. She could not arrange these words in a meaningful way, supporting the idea of a critical period in language development.

Rigler's research was disorganized and largely anecdotal. Without funds to continue the research and care for Genie, she was moved from the Riglers' care.

In 1975, Genie returned to live with her birth mother. When her mother found the task too difficult, Genie was moved through a series of foster homes, where she was often subjected to further abuse and neglect .

Genie’s situation continued to worsen. After spending a significant amount of time in foster homes, she returned to Children’s Hospital. Unfortunately, the progress that had occurred during her first stay had been severely compromised by the subsequent treatment she received in foster care. Genie was afraid to open her mouth and had regressed back into silence.

Genie’s birth mother then sued the Children’s Hospital of Los Angeles and the research team, charging them with excessive testing. While the lawsuit was eventually settled, it raised important questions about the treatment and care of Genie. Did the research interfere with the girl's therapeutic treatment?

Psychiatrist Jay Shurley visited her on her 27th and 29th birthdays and characterized her as largely silent, depressed , and chronically institutionalized. Little is known about Genie's present condition, although an anonymous individual hired a private investigator to track her down in 2000 and described her as happy. But this contrasts with other reports.

Genie Wiley Today

Today, Genie Wiley's whereabouts are unknown; though, if she is still living, she is presumed to be a ward of the state of California, living in an adult care home. As of 2024, Genie would be 66-67 years old.

Part of the reason why Genie's case fascinated psychologists and linguists so deeply was that it presented a unique opportunity to study a hotly contested debate about language development.

Essentially, it boils down to the age-old nature versus nurture debate. Does genetics or environment play a greater role in the development of language?

Nativists believe that the capacity for language is innate, while empiricists suggest that environmental variables play a key role. Nativist Noam Chomsky suggested that acquiring language could not be fully explained by learning alone.

Instead, Chomsky proposed that children are born with a language acquisition device (LAD), an innate ability to understand the principles of language. Once exposed to language, the LAD allows children to learn the language at a remarkable pace.

Critical Periods

Linguist Eric Lenneberg suggests that like many other human behaviors, the ability to acquire language is subject to critical periods. A critical period is a limited span of time during which an organism is sensitive to external stimuli and capable of acquiring certain skills.

According to Lenneberg, the critical period for language acquisition lasts until around age 12. After the onset of puberty, he argued, the organization of the brain becomes set and no longer able to learn and use language in a fully functional manner.

Genie's case presented researchers with a unique opportunity. If given an enriched learning environment, could she overcome her deprived childhood and learn language even though she had missed the critical period?

If Genie could learn language, it would suggest that the critical period hypothesis of language development was wrong. If she could not, it would indicate that Lenneberg's theory was correct.

Despite scoring at the level of a 1-year-old upon her initial assessment, Genie quickly began adding new words to her vocabulary. She started by learning single words and eventually began putting two words together much the way young children do. Curtiss began to feel that Genie would be fully capable of acquiring language.

After a year of treatment, Genie started putting three words together occasionally. In children going through normal language development, this stage is followed by what is known as a language explosion. Children rapidly acquire new words and begin putting them together in novel ways.

Unfortunately, this never happened for Genie. Her language abilities remained stuck at this stage and she appeared unable to apply grammatical rules and use language in a meaningful way. At this point, her progress leveled off and her acquisition of new language halted.

While Genie was able to learn some language after puberty, her inability to use grammar (which Chomsky suggests is what separates human language from animal communication) offers evidence for the critical period hypothesis.

Of course, Genie's case is not so simple. Not only did she miss the critical period for learning language, but she was also horrifically abused. She was malnourished and deprived of cognitive stimulation for most of her childhood.

Researchers were also never able to fully determine if Genie had any pre-existing cognitive deficits. As an infant, a pediatrician had identified her as having some type of mental delay. So researchers were left to wonder whether Genie had experienced cognitive deficits caused by her years of abuse or if she had been born with some degree of intellectual disability.

There are many ethical concerns surrounding Genie's story. Arguments among those in charge of Genie's care and rehabilitation reflect some of these concerns.

"If you want to do rigorous science, then Genie's interests are going to come second some of the time. If you only care about helping Genie, then you wouldn't do a lot of the scientific research," suggested psycholinguist Harlan Lane in the NOVA documentary focused on her life.

In Genie's case, some of the researchers held multiple roles of caretaker-teacher-researcher-housemate. which, by modern standards, we would deem unethical. For example, the Riglers benefitted financially by taking Genie in (David received a large grant and was released from certain duties at the children's hospital without loss of pay). Butler also played a role in removing Genie from the Riglers' home, filing multiple complaints against him.

While Genie's story may be studied for its implications in our understanding of language acquisition and development, it is also a case that will continue to be studied over its serious ethical issues.

"I think future generations are going to study Genie's case not only for what it can teach us about human development but also for what it can teach us about the rewards and the risks of conducting 'the forbidden experiment,'" Lane explained.

Bottom Line

Genie Wiley's story perhaps leaves us with more questions than answers. Though it was difficult for Genie to learn language, she was able to communicate through body language, music, and art once she was in a safe home environment. Unfortunately, we don't know what her progress could have been had adequate care not been taken away from her.

Ultimately, her case is so important for the psychology and research field because we must learn from this experience not to revictimize and exploit the very people we set out to help. This is an important lesson because Genie's original abuse by her parents was perpetuated by the neglect and abandonment she faced later in her life. We must always strive to maintain objectivity and consider the best interest of the subject before our own.

Frequently Asked Questions

Genie, now in her 60s, is believed to be living in an adult care facility in California. Efforts by journalists to learn more about her location and current condition have been rejected by authorities due to confidentiality rules. Curtiss has also reported attempting to contact Genie without success.

Along with her husband, Irene Wiley was charged with abuse, but these charges were eventually dropped. Irene was blind and reportedly mentally ill, so it is believed that Genie's father was the child's primary caretaker. Genie's father, Clark Wiley, also abused his wife and other children. Two of the couple's children died in infancy under suspicious circumstances.

Genie's story suggests that the acquisition of language has a critical period of development. Her case is complex, however, since it is unclear if her language deficits were due to deprivation or if there was an underlying mental disability that played a role. The severe abuse she experienced may have also affected her mental development and language acquisition.

Collection of research materials related to linguistic-psychological studies of Genie (pseudonym) (collection 800) . UCLA Library Special Collections, Charles E. Young Research Library, University of California, Los Angeles.

Schoneberger T. Three myths from the language acquisition literature . Anal Verbal Behav. 2010;26(1):107–131. doi:10.1007/bf03393086

APA Dictionary of Psychology. Language acquisition device . American Psychological Association.

Vanhove J. The critical period hypothesis in second language acquisition: A statistical critique and a reanalysis .  PLoS One . 2013;8(7):e69172. doi:10.1371/journal.pone.0069172

Carroll R. Starved, tortured, forgotten: Genie, the feral child who left a mark on researchers . The Guardian .

James SD. Raised by a tyrant, suffering a sibling's abuse . ABC News .

  NOVA . The secret of the wild child [transcript]. PBS,

Pines M. The civilizing of Genie. In: Kasper LF, ed., Teaching English Through the Disciplines: Psychology . Whittier.

Rolls G.  Classic Case Studies in Psychology (2nd ed.). Hodder Arnold.

Rymer R. Genie: A Scientific Tragedy.  Harper-Collins.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Child Psychology

Child Psychology studies how children grow, learn, and develop. It helps us understand young minds’ thought processes, exploring the mysteries of their thoughts and behaviours. Child psychology studies the unique challenges and experiences children face in the early phases of life i.e. infancy, childhood, and adolescence.

Understanding child psychology is important for parents and educators to give effective support and guidance to the children. By studying different aspects of child psychology, we can understand the factors that influence children’s development. In this article, we will find child psychology notes, its importance and more.

Table of Content

What is Child Psychology?

Who is the father of child psychology, history of child psychology, contexts in child psychology, types of child psychology, influences of child psychology on behavior, importance of child psychology, conclusion – child psychology, faqs on child psychology.

Child psychology is a field of study focused on understanding how children think, feel, and behave as they grow and develop. Child psychology examines various aspects of childhood, including cognitive, emotional, and social development. This field of psychological studies plays an important role in helping parents, educators, and caregivers better understand children’s needs and behaviours. By studying child psychology, researchers aim to identify the patterns and trends in children’s behaviour, development, and support strategies.

The father of child psychology is commonly recognized as Jean Piaget, a Swiss psychologist. Piaget’s research emphasized the importance of children’s cognitive development and proposed stages of intellectual growth, such as the sensorimotor, preoperational, concrete operational, and formal operational stages. His theories have profoundly influenced educational practices and our understanding of child development worldwide.

The evolution of child psychology involves the studies of many eminent scientists and psychologists, some of whom are listed here.

• G. Stanley Hall in 1896 established the first psychological research laboratory in the United States, pioneering the study of child development.
• Jean Piaget , in the 20th century, gave theories on cognitive development.
• Erik Erikson’s work in the mid-20th century gave the theory of psychosocial development, focussing on the role of social interactions in shaping identity.
• Lev Vygotsky , at around the mid-20th century, gave the socio-cultural theory, highlighting the significance of cultural influences on children’s cognitive development.

In Child Psychology, understanding various contexts is crucial as they strongly influence children’s development and behaviours.

Cultural Context

It refers to the cultural environment in which a child grows up. This includes aspects such as cultural beliefs, traditions, language, and customs that influence a child’s development and identity formation.

Social Context

It refers to a child’s social environment, including family dynamics, peer relationships, and community influences. It examines how social interactions, role models, and societal expectations impact a child’s socialization, emotional development, and behaviour.

Socioeconomic Context

It refers to the economic circumstances in which a child grows up, including family income, access to education, healthcare, and community resources. It examines how socioeconomic factors influence a child’s opportunities, resources, and overall well-being.

Child Psychology is divided into further divisions to better understand children and how to support their development.

• Developmental Psychology: This branch focuses on how children grow, learn, and change over time.
• Clinical Child Psychology: This field deals with the understanding and treating emotional, behavioral, and mental health issues in children. Clinical child psychologists work with children facing challenges such as anxiety, depression, trauma, and behavioral disorders.
• Educational Psychology: This branch focuses on how children learn and develop within educational settings. This includes studying factors that influence learning, such as motivation, attention, memory, and problem-solving skills.
• Social Psychology: It focuses on how children’s thoughts, feelings, and behaviors are influenced by their social environment.
• Cognitive Psychology: In the context of child psychology, cognitive psychologists investigate how children think, learn, and make sense of the world around them. They study topics such as language development, decision-making, and the development of cognitive skills.
• Milestones Psychology: This branch focuses on tracking and understanding the significant developmental achievements that children reach at different stages of their lives.
• Emotional Psychology: This branch includes studying how children recognize, understand, and regulate their emotions, as well as how they express and respond to the emotions of others.

Child Psychology plays an important role in understanding and shaping children’s behaviours. By studying the role of cognitive, emotional, and social factors, psychologists can identify underlying causes of behaviour. Through child psychology, parents, educators, and caregivers understand how children learn, communicate, and regulate their emotions, which helps in forming strategies to manage challenging behaviours. By applying principles from child psychology, professionals can promote positive behaviours and emotional well-being in children.

Child Psychology is very important branch of psychological studies as it helps us to understand the thought process and understandings of a child. It has the following importances;

• It helps us study how children grow physically, mentally, emotionally, and socially.
• It enables us to understand the challenges early on that lead to more positive outcomes for children in the long run.
• Helps to promote the positive mental health in children.
• It helps parents, caregivers, and educators build stronger relationships with children.
• Helps to prevent negative outcomes such as academic failure, social isolation, and mental health disorders later in life.

Child psychological studies offer detailed information into the world of childhood development and behaviour. Through research and clinical observations, psychologists have understood the factors influencing children’s growth and well-being. By studying the contexts such as cultural, social, and socioeconomic factors, child psychological studies provide a framework for supporting children’s development. Child psychological studies serve as a cornerstone for promoting the healthy development of the next generation.

Also Read: Difference Between Adolescence and Puberty NCERT Notes Science for Class 8 Chapter – 7: Reaching The Age of Adolescence Adolescence and Drug Abuse Physical Changes at Puberty RCH – Reproductive and Child Health

What is the Aim of Child Psychology?

Child Psychology aims to understand and explain how children grow, think, and behave.

The Father of Child Psychology is often considered to be Jean Piaget.

What is Theory in Child Psychology?

A theory in Child Psychology is a systematic framework used to explain and predict children’s behaviour and development.

What are the Types of Child Psychology?

The types of Child Psychology include developmental psychology, clinical psychology, educational psychology, and social psychology.

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