The role of attachment and resiliency in the intergenerational transmission of depression:

results from the Cambridge Longitudinal Study

Lynne Murray

Winnicott Research Unit, University of Reading

withAdriane Arteche, Peter Cooper, Sarah Halligan, Pasco Fearon and Matt Woolgar

Funding: MRC, UK; Tedworth Trust; Winnicott Trust

Intergenerational transmission of depression

• Consistent reports of offspring of parents with depression being at substantially increased risk for depression themselves: - e.g., Leib et al., 2002Lewinsohn et al., 2005Weissman et al., 2006Timko et al., 2008

• However, little prospective longitudinal data concerning development of disorder through childhood.

How might insecure attachment be involved in intergenerational transmission

of psychopathology?

Bowlby’s theory of attachment

• Concerns propensity to make close emotional bonds

• Need for protection a prominent feature early in development

• Security promotes independence

Attachment quality

• Secure: can rely on parent for support when distressed

• Insecure avoidant: minimize expression of distress, avoid close contact

• Insecure ambivalent: maximize expression of distress at separation, mixed with anger

• Disorganised: no clear strategy, confused, irrelevant, freezing

Parenting and attachment

• Secure: available, responsive, sensitive

• Insecure avoidant: rejection

• Insecure ambivalent: inconsistent

• Disorganised: frightening behaviour/ maltreatment

Bowlby’s view of mental health implications

• Avoidant– Deny needs – Attempt to live without others’ love and support– Sense of self as not worthy of love– Low expectations of others

• Ambivalent– Pervasive anxiety, especially re. separation/abandonment– Limited exploration of world– Coping capacities not developed

Characteristics of attachment

• Repeated patterns of interaction become internalised as IWM’s

• Self-perpetuating

• Relatively flexible early on, but become more fixed over time

• Early experience special, as provides ‘setting point’

Evidence to date: Minnesota longitudinal study of mental health outcomes

• Avoidant/disorganized – predicts more global pathology (Sroufe, 2005)

• Ambivalent – predicts anxiety diagnoses (Warren, 1997)

• Avoidant – predicts externalizing, early onset antisocial (Aquilar, 2000; Sroufe, 2005)

• Disorganised – predicts dissociation (Carlson, 1998) other disorders (Liotti, 2004; 2008)

• NB not strong effects, adversity adds

Role of attachment insecurity in transmission of depression

• Depressed mothers’ interactions:

Generally insensitive –

- Withdrawn, unresponsive

- Intrusive, hostile

Effects of depression on infant attachment

Systematic associations shown between PND and insecure attachment

Meta analyses-

Martins and Gaffan, 2000

Atkinson et al., 2000

Plus

Campbell et al., 2004 (NICHD sample)

Bowlby’s view of mental health implications of attachment for ego resiliency

• Avoidant– Deny needs – Attempt to live without others’ love and support– Sense of self as not worthy of love– Low expectations of others

• Ambivalent– Pervasive anxiety, especially re. separation/abandonment– Limited exploration of world– Coping capacities not developed

Ego resiliency

Thus, the insecure child may:-

lack capacity to cope with threat

have rigid, or limited coping strategies

be overwhelmed with sense of loss/anxiety

have low self-worth

(Erikson, 1985)

Predicted pathway

PND insecurity low ego resiliency depression

Cambridge longitudinal study

• Sample

• Low risk mothers cohabiting/married

• Infants healthy

• Community sample screened at 6 weeks

• 58 depressed, 42 controls recruited

• Assessed so far to 16 years

video clips of interactions

Key child assessments beyond postnatal period

• 18 months- attachment

• 5 years- ego resiliency

• 8 years- ego resiliency

• 16 years- psychiatric outcome

Other potentially important influences

• Continuing quality of mother-child relationship

• Chronicity of maternal depression

• Marital conflict

Occurrence of depression assessed 8-16 years

• At each time point, a standardised interview (the K-SADS) was used, and administered by a researcher unaware of maternal diagnosis, to mother and child independently

• At 8 years current state was assessed• At 13 and 16 years current and previous mental state

to previous assessment was assessed• Diagnoses assigned by senior clinical team, according

to best estimate, combining maternal and child report.

Cambridge Longitudinal study: Depression in the children 8-13 years

0

5

10

15

20

25

30

35

40

45

50

Any Diagnosis

Depression Anxiety Behavioural

Per

cent

Dis

orde

r

Control (n=41)PND (n=53)

**

*

Depression begins to emerge at 11-yrs: higher rates of depressive disorder present in the PND group by 13-yrs

Cambridge Longitudinal study: Depression in the children 13 to 16-years

05

101520253035404550

Any Diagnosis

Depression Anxiety Behavioural

Perc

en

t d

iso

rder

Control (n=40)PND (n=53)

**

***

Rates of disorder continue to increase, particularly because of the emergence of depression in the PND group

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

0

10

20

30

40

50

% Depressed

X2(1)=9.31; p<.01

%

Control

PND

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

PND & DEPRESSION OUTCOME - BOYS

0

10

20

30

40

50

% Depressed

X2(1)=6.17; p=.01

%

Control

PND

PND & DEPRESSION OUTCOME - GIRLS

0

10

20

30

40

50

% Depressed

X2(1)=3.56; p=.05

%

Control

PND

Developmental trajectory to depression

The roles of infant attachment and ego resiliency, and the subsequent mother-child relationship

Insecure infant attachment: Effects of PND

0

20

40

60

80

100

% Insecure

X2(1)=14.01; p<.001

% Control

PND

Infant attachment: Relation to 16 years lifetime depression

0

20

40

60

80

% Insecure

X2(1)=3.73; p<.05

%

Not Depressed

Depressed

Ego resiliency at 5 and 8 years: Effects of PND and attachment, and relation to 16 yr

life-time depression

• The Snap card game (Murray et al., 2001)

• Child at home with friend• Competitive card game• Rigged by experimenter to provide losing and

winning deals (both children win at end!)• Rate child’s distress and anxiety in the face of the

mild threat of loss

video clips of card game

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

0

5

10

15

20

5yr ER 8yr ER

F(1,88)=4.22, p<.05 F(1, 80)=3.17, p<.10

MEAN

Control

PND

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

0

5

10

15

20

5yr ER 8yr ER

F(1,88)=2.47, ns F(1, 80)=3.67, p<.10

MEAN

Secure

Insecure

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

0

5

10

15

20

5yr ER 8yr ER

Wald=3.36, OR=1.07, p<.10 Wald=7.67, OR=1.07, p<.01

MEAN

Not Depressed

Depressed

Maternal sensitivity and emotional support at 5 and 8 years

• Maternal sensitivity at 5 years- assessed during ‘snack’ in research unit (warmth, appropriate responsiveness) (Murray et al., 1999)

• Maternal emotional support at 8 years- assessed during child homework session (available, positively responsive) (Murray et al., 2006)

Maternal insensitivity at 5 years: Effects of PND

1

2

3

4

Insensitivity

MEAN

no PND

PND

PND effects: F(1, 84)=2.91, p<.10

sex effects: nsPND*sex: ns

+

Maternal insensitivity at 5 years: Effects of attachment

1

2

3

4

Insensitivity

MEAN

Secure

Insecure

attachment effects: F(1, 84)=2.90, p<.10

sex effects: nsattachment*sex: ns

+

Maternal insensitivity at 5 years: Relation to adolescent depression

1

2

3

4

Insensitivity

MEAN

No Depression

Depression

*

No effects of 8 yr emotional support

Pathway so far: PND, attachment, 5 and 8 yr resiliency, and maternal insensitivity at 5 yrs

PNDInfantAttach

ER 8yrs

5yrsinsensitivity

16y lifetime

depression

p=.05

ER5yrs

p=.09

p=.05 p=.006p=.06p=.06 p=.06

p=.05

p<.001

p=.004

The role of chronic difficulties

• Maternal depression– Assessed at each time point, with month-by-month

recording of offsets and onsets of disorder to give chronicity

• Marital conflict– Assessed at each time point by interview/questionnaire

Chronicity of maternal depressionWomen in the PND group experienced further

depression outside the postnatal period

Marital conflict: Relation to PND

0

10

20

30

40

50

60

70

80

18m MC 5y MC 8y MC 13y MC

% No PND

PND

**

**

**

What about continuing maternal depression & marital conflict? Effects of these difficulties following each stage of child development

attachment

18m Depression <16yrs

chronicity mat. depression

p<.01

marital conflict at 18m, 5, 8 & 13y

p=.04

low ego resilience 5y

Depression <16yrsMODEL 1 attach 18m

chronicity mat. depression (5y-onset)

p<.05

marital conflict 5+8 +13p=.06

MODEL 2attach18m

low egoresilience 5y

chronicity mat. depression (8y-onset)

ns

Depression <16yrs low ego

resilience 8y

marital conflict at 8+ 13y ns

What about mother-child interactions?

attachment 18m

Depression <16yrs

maternal insensitivity at 5yrs

p<.10

maternal emotional support at 8yrs

ns

low ego resilience 5y

MODEL 1

maternal emotional support at 8yrs

ns

Depression <16yrs attachment

18m

maternal insensitivity at 5yrs

ns

Summary

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

Supplementary findings: a) the role of subsequent maternal interactions

• Once infant attachment is taken into account, the contribution of maternal insensitivity at 5 yrs is only marginal. That of 8yr maternal support is not significant.

• Once infant attachment and 5yr resiliency are taken into account, the mother’s insensitivity at 5 yrs does not contribute further to risk of depression (and 8yr support remains non-significant)

Supplementary findings: b) the role of further maternal depression and conflict

• Once infant attachment is taken into account, there is still an additional effect of continuing maternal depression and marital conflict

• Once attachment and 5yr resiliency are taken into account, the effect of continuing maternal depression is still significant, but the role of subsequent marital conflict is reduced

• Once attachment and both 5 and 8yr resiliency are taken into account, neither further maternal depression, nor marital conflict add to the risk of child depression

Overall conclusion

• PND and its effects on child development through the first 8 years predict the occurrence of child depression up to 16 years.

• Negative experience subsequent to the first 8 years does not add further to the child’s risk of depressive disorder