Assessing attachment status in adults with intellectual disabilities: the potential of the Adult Attachment Projective Picture System

Published date03 March 2014
Date03 March 2014
Pages103-119
DOIhttps://doi.org/10.1108/AMHID-10-2012-0004
AuthorDeanna J Gallichan,Carol George
Subject MatterHealth & social care,Learning & intellectual disabilities,Accounting education
Assessing attachment status in adults
with intellectual disabilities: the potential
of the Adult Attachment Projective
Picture System
Deanna J. Gallichan and Carol George
Dr Deanna J. Gallichan is a
Clinical Psychologist, based at
Community Learning
Disabilities Team, Plymouth
Community Healthcare CIC,
Plymouth, UK.
Carol George is a Professor of
Psychology, based at
Department of Psychology,
Mills College, Oakland,
California, USA.
Abstract
Purpose – The purpose of this paper is to explore the potential of the Adult Attachment Projective Picture
System (AAP) as a measure of attachment state of mind in adults with intellectual disabilities. The AAP is a
free response picture system method of assessing patterns of adult attachment with established validity and
reliability in community and clinical samples.
Design/methodology/approach – The paper reports on five cases of adults with intellectual disabilities
who were administered the AAP as part of routine clinical work. The AAP administration procedure was
modified to take account of the participants’ intellectual disabilities.
Findings – It was possible to code and classify each AAP using the established coding and classification
system. The authors coded four cases blind to each other’sclassification; they agreed on classifications for
three cases and reached consensus on the fourth. The AAP analysis showed strong correspondence with
case history material.
Originality/value – The AAP demonstrates the potential to assess attachment state of mind in adultswith
intellectual disabilities and is the first developmental measure of attachment status that has shown potential
in this population. The paper discusses clinical application of the AAP and directions for future research.
Keywords Intellectual disabilities, Attachment, Trauma, AAP
Paper type Case study
Introduction
For over 25 years, researchers and clinicians interested in adult attachment have used the
concept of “internal working models” to describe how adults evaluate and think about their
attachment experiences, a representational process also termed attachment “state of mind”
(Hesse, 2008; Dozier et al., 2008; Solomon and George, 2011). Whilst there has been
increasing interest in the contribution of attachment to the clinical problems presented by
people with intellectual disabilities (Schuengel and Janssen, 2006), no studies to date have
attempted to measure the “internal working models” of adults in this population. Assessment
seems to be the main methodological roadblock in extending attachment concepts to adults
with intellectual disabilities.
To date, there are only two published studies attempting to apply standardised measures of
attachment to adults with intellectual disabilities. Minnis et al. (2010) modified a questionnaire
designed to identify symptoms of reactive attachment disorder (RAD) in children in a study
of 50 adults with varying degrees of intellectual disabilities. RAD is a severe and atypical
form of attachment disorder observed in children who experience severely compromised care
Plymouth Community Healthcare
(CIC) was formerly part of NHS
Plymouth. The authors wish to
thank; Dr Judith McBrien, who
arranged funding for the first
author’s AAP training via the
Developmental Disabilities
Research and Education Group
(hosted by Plymouth University);
Professor Malcolm West, who
co-facilitated the AAP training
seminar with Dr George;
Ms Kay Hughes who has
supported the first author in
maintaining research time;
all of the clients who consented
to participate in this study.
DOI 10.1108/AMHID-10-2012-0004 VOL. 8 NO. 2 2014, pp. 103-119, CEmeraldGroup Publishing Limited, ISSN 2044-1282
j
ADVANCES IN MENTAL HEALTH AND INTELLECTUAL DISABILITIES
j
PAGE 103
(e.g. poor quality institutional care, severe maltreatment). Minnis et al. concluded that RAD
symptoms were present in their sample as related to experiences of childhood adversity (e.g.
abuse, neglect), not level of intellectual disabilities. These findings parallel those of studies of
children with intellectual disabilities (van IJzendoorn et al., 1992), suggesting the importance of
considering attachment experiences as a risk factor for adult problems separate from disability
status. Although this study broadened thinking regarding the origins of clinical problems in this
population, the RAD questionnaire was not standardised or validated for adults (intellectually
disabled or typical). Moreover, the study was not able to offer insights regarding how problems
may be related to the standard patterns of attachment “state of mind”, patterns that are not
isomorphic with RAD (Zeanah et al., 2005).
Larson et al. (2011) explored the association between romantic attachment style and
behavioural and mental health problems in a sample of adults with intellectual disabilities using a
modified version of Hazan and Shaver’s (1987) questionnaire. Although Larson et al. articulated
their study goals from a developmental perspective, the use of an attachment style measure
obscures the capacity to elucidate the developmental foundations of the phenomena they
sought to describe. Attachment style appears on the surface to be grounded in the same
underlying phenomenon as the developmental construct; however, this social personality
construct has no established empirical link with childhood experience (Crowell et al., 2008;
George and West, 1999, 2012). Early attachment style researchers sought to explain adult
loneliness, and attachment style in its contemporary form is a model of personality based on
social cognitive evaluations of romantic adult relationships (Crowell et al., 2008; George and
West, 1999). Most importantly for our work here, there is no meaningful overlap between
developmental attachment and attachment style in concept or measurement (de Haas et al.,
1994; Roisman et al., 2007).
Neither study, therefore, informs us about how adults with intellectual disabilities may evaluate
and think about their early attachment experiences. We now explore the potential of using
representational developmental attachment assessments with adults with intellectual
disabilities.
Developmental assessments of adult attachment
The Adult Attachment Interview (AAI)
The AAI (George et al., 1984/1985/1996; Main and Goldwyn, 1985/1988/1994; Main et al.,
2003) is the gold standard developmental adult attachment measure, and has been used with
individuals in community and clinical samples for over 25 years (Hesse, 2008). Why has it not
been used with adults with intellectual disabilities? An examination of the demands of the AAI
administration and coding highlights several potential confounds that threaten its validity for use
with this population.
The AAI is a lengthy interview (18 questions, one to two hours administration time) during which
the interviewer guides the individual in creating a verbal picture of childhood attachment
experience and reflections on how these experiences influence current evaluations of self and
attachment figures (Hesse, 2008). The interview begins with instructions to select five words to
describe an individual’s relationship with each of their attachment figures (e.g. mother, father).
The interviewee is asked to describe memories, details, and evaluations of separation, rejection,
loss, and abuse (George et al., 1984/1985/1996). The reflection questions are abstract, for
example: “How do you think your overall early experiences have affected your adult personality?
Or, are there any aspects you would consider a setback to your development?” (George et al.,
1984/1985/1996). In order for the AAI to be valid, every question must be presented in the
same order, questions cannot be paraphrased, and they must be answered only by the
interviewee. The interview is not supplemented with collateral or confirmatory information
obtained from others (George et al., 1984/1985/1996). Lengthy verbal conversations can
be very difficult for many people with intellectual disabilities, even for those who use language to
communicate, suggesting that the interview experience could be unwieldy for many individuals
in this population.
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VOL. 8 NO. 2 2014

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