Perception of attachment security in families with children affected by neurological illness

This study analyzes inter-family relationships of families with children with neurological problems using Bowlby’s attachment theory as model of reference. The research was conducted in two hospitals in Serbia specialized in neurological diseases: cerebral palsy and epilepsy. It is hypothesized that neurological problems could be associated to a discrepancy of inter-family attachment perceptions. Two groups were selected, a clinical one composed of 25 nuclear families: mother, father and child with a certified diagnosis of either cerebral palsy or epilepsy; and a control group of 25 nuclear families: mother, father and child with no pathology. Kerns, Klepac and Cole’s Security Scale (1996) was used for the investigation, with the addition of two modified version for administration to the parents. Data analysis demonstrated that the clinical group is substantively higher (p=.076) with respect to the discrepancy of attachment perceived by the children and the attribution of meaning that parents give to their child’s attachment perception towards them. Further analyses carried out on parent-child relationships demonstrated a significant difference (p =.017) between the clinical and control groups, with respect to the perception of father-child attachment. We conclude that in the clinical group, there is a discrepancy of attachment perceptions that particularly affects the father-child relationship. It appears that hospitalization and the consequent separation of the nuclear families may influence the formation of secure attachment relationships, in particular between father and child.

As scientific literature shows, many different factors influence attachment bonds and care-giving capabilities.Attachment is generally conceptualized as the affectional bond or tie that infants develop with their attachment figure during the first year of life (Ainsworth, Blehar, Waters, & Wall, 1978).Bowlby (1969) defined attachment as the child's strong disposition to seek proximity to and contact with a specific figure and to do so in certain situations, notably when he/ she is frightened, tired or ill.Patterns of attachment behavior reflect the child's anticipations about parental reactions to bids for comfort.These anticipations, in turn, guide child strategies for regulating negative emotions and managing A study by Mullen (1997) on the relationship between Cerebral Palsy and the development of attachment bonds concludes that it is neither the presence nor the gravity of this pathological condition that influences the type of attachment.Instead, the pathology turns out to be more connected to the stress level of the caregiver and its gravity seems to increase the stress level and the risk of an insecure attachment.Marvin and Pianta (1996), in particular, examined in detail attachment developments in a group of children affected by Cerebral Palsy and Epilepsy.In addition to analyzing the impact of the two illnesses on attachment development, the authors also performed parallel investigations on the same group of subjects with the objective of evaluating the parents' response to the child's diagnosis using a structured interview (Response to Diagnosis Interview, RDI) and the parental attachment style through the Adult Attachment Interview, or AAI.In the light of the results obtained, the authors concluded that children with illnesses are at higher risk of developing insecure attachments when compared to the general population.Specifically, children with epilepsy had a higher probability of developing a disorganized attachment style.Furthermore, correlations between low RDI scores in parents and the risk of insecure attachment in the child were noted as well as between insecure attachment styles in parents and their having a negative type of response to the diagnosis.
In our study, we hypothesize that the neurological illness could be associated to a high discrepancy of attachment perceptions within the family context, resulting in less secure bonds, with respect to subjects without this type of problem.This might depend on the complex dynamics that take place within the nuclear family, the context within which all the caregiver's investments and expectations from their child exist.Differently from the previous research which mainly focused on the mother-child dyad, this paper aims to evaluate the attachment relationships within the mother-father-child triad.In detail, it investigates the degree of discrepancy/concordance regarding the child's security perception towards parents and the parents' attachment perceptions, in terms of beliefs about their being secure parents and also recognizing the child's attachment towards them.

Method
The recruited subjects.The group is composed of 50 nuclear families (mother, father, child): all children are aged between 7 and 19 years old and are Serbian residents.The clinical group is composed of 25 nuclear families; specifically 19 with children affected by cerebral palsy and 6 with epilepsy.The remaining 25 nuclear families make up the control group, whose children do not have any pathology and are matched to the clinical subjects by age and gender.
No differences were detected between clinical and control group by both age, t (48) = -1,064, p = .293and gender, χ 2 (1, N = 50) = 0.80, p = .777.The two groups are thus wellbalanced.The subjects of the clinical group were recruited through two hospitals: a specialized hospital for Cerebral Palsy which includes two structures (a residential structure that takes inpatients from their first months of life until adulthood; and a Day Hospital); and the outpatient ward of a hospital specialized in infant and adolescence neurology.Six subjects, 5 females and 1 male, were recruited from the residential structure.Thirteen subjects, 6 females and 7 males, were recruited from the Day Hospital.The control group was selected from 2 public schools: a high secondary school in Belgrade and a low secondary school in Kragujevac.
The group was selected using the following criteria: For the clinical subjects: Instrument.The instrument used for the investigation is the Security Scale (SS) of Kerns, Klepac andCole (1996, as cited in Calvo, 1998) translated in Serbian.The original scale was dedicated to children aged 6-11 years, but for this study a supplementary version was also used for the adolescents (set up by one of us) applicable to subjects aged 12-19 years.Two other scales were created ad hoc for the parents based on the scale model applied to children and adolescents.The SS is a self-administered questionnaire composed of 30 items that measure the attachment perception of the child towards the parents (we named it CP, i.e. child-parents).Of these 30 items the first 15 were based on the attachment perception of the child towards the mother (we named it Subscale CM) while the other 15 were based on the attachment perception towards the father (we named it Subscale CF).Therefore, the test could be seen as composed by two subscales.For each item, the child has to choose out of four options the one closest to his/her actual personal experience.To facilitate understanding, the authors created the items according to Harter's method (1982), dividing each item into two counterposed parts such as: "Some children...INSTEAD, other children...".Each response is assigned with a numerical value from 1 to 4 and the sum of all the responses determines the total score.The attachment score ranges from 30 to 120 points.In contrast, the sum of the responses of only one of the subscales will obtain a total score ranging from 15 to 60, indicating the child's attachment perception towards each of the parents.The scales for the parents (respectively, M for the mother and F for the father) are structured in the same way and include two subscales.The first subscale (What kind of mother/father am I, respectively M1/P1) is composed of 15 items and aims to verify the attachment perception of the parent towards the child on a range of scores from 15 to 60 and reflects the scale for the child.The second (What kind of mother/father does my child think I am, respectively M2/ P2) is also composed of 15 items and investigates how the parent believes s/he is perceived by his/her child in terms of attachment.Therefore, from the first scale (M1/F1), it is possible to obtain a score that reflects the score of the child.In this sense, the comparison between the scores obtained by the child and those obtained by the parents in this subscale may provide a value of discrepancy between the perceived attachment of the child towards the parent and that of the parent towards the child as a secure and competent parent.Instead, the second scale (M2/F2) provides the score for the attribution that each parent gives to the attachment perceived by the child towards him/her.In other words, it indicates the way in which the parent believes to be perceived by the child.In this case, the comparison between the scores obtained by the child and those obtained by the parents in this subscale provides an index of how much the attachment perception the parent attributes to the child corresponds to the actual attachment perception of the child.From the Security Scale, therefore, we can derive indications on how the child represents him/herself and describes his/her actual relationships with significant adults (Calvo, 1998(Calvo, , 2008a(Calvo, , 2008b)).The scores obtained are dimensional and not categorical, therefore the instrument does not allow to detect the child's attachment style and to classify it as secure or insecure, but is able to provide an indicative measure of the perception of security.
Statistical procedures.In order to compare the measures of each family subject (mother/ father/child) from the different scales used, we standardized the raw total score of each scale/ subscale (based on the whole sample) and obtained a z score with a mean of zero and a standard deviation equal to 1.The standardization was carried out because of the different score ranges of each measure which don't allow the comparisons across all the scales/ subscales used.
Then, to determine the degree of discrepancy/concordance of security in attachment perceptions within the family relationships, we calculated a dispersion index (standard deviation) taking into account the standard scores derived from the following scales: CP -M -F: general security in attachment perceptions of the child, mother and father CP -M1 -P1: general security in attachment perception of the child and specific attachment perceptions of mother and father as secure parents; CP -M2 -P2: general security in attachment perception of the child and specific attachment perceptions of the mother and father about the security perceived by the child.SPSS 16.0 package was used for statistical analyses.In more detail, T-test for independent samples is used to compare the clinical and control groups in respect with both the standard scores in each scale/subscale and all the discrepancy indexes considered.Because the specific medical ward (residential and day hospital) and kind of neurological illness (epilepsy and cerebral palsy) could affect our results within the clinical group, we decided to carry out preliminary analyses to test whether some differences in both scales/subscales and discrepancy indexes measures exist based on these variables.

Results and Discussion
Results suggest that no difference in clinical subjects exists, depending on medical ward or kind of disease, with regard to the different measures of attachment security (p> .05).
In Table 2 standard scores of each scale/subscale are shown, which overall highlight the low security in attachment perceptions of the clinical subjects for all the measures considered.In more detail, T-test analysis reveals the lower security in attachment perceptions of the child towards both the father (subscale CF), t (48) = -2.274,p = .028;and parents (scale CP), t (48) = -2.190,p = .034,compared to the control group.Regarding the comparison of the discrepancy indexes within the family attachment relationships between the control and clinical group, the results of T-test analyses show a substantive -but not statistically significant -difference (p = .076).Indeed, families with children affected by neurological illness show higher discrepancy in respect of the security in attachment perception of the child and the attribution that each parent gives to the security in attachment perceived by the child towards him/her (Table 3).To investigate the trend observed with respect to this substantive discrepancy, we conducted further analyses considering the difference between the subgroups by gender and age and also evaluating this discrepancy in relation to each single dyad.
With regards to the discrepancies in the families with male children, a significant value (p = .032)emerged in comparing the clinical group with the control group.Repeating the same comparison in families with female children, no significant data emerged instead (Table 4).Looking at the different standard scores across the family subjects in the clinical subgroup with male children, we note that this discrepancy is mostly due to the low security in attachment perception of the child (M = -0.33,SD = 1.16) in respect with that of the mother (M = -0.12,SD = 0.83) and of the father (M = -0.11,SD = 0.86).
With regards to the subgroups by age range (Table 5), the discrepancy in the families with children aged 7-12 is significantly higher in the clinical group compared to the control group (p = .028).No difference is detected in the subgroup with children aged 13-17 instead.In more detail, this discrepancy seems to derive from a very low security in attachment perception of the child (M = -0.45,SD = 0.96) compared to the attributions that both the mother (M = 0.19, SD = 0.95) and the father (M = 0.03, SD = 1.05) give to the attachment perceived by the child towards each of them.
It is possible to conclude that in the clinical group there is a slight discrepancy between how the child perceives a secure relationship with the parents and the perception each parent has on the security experienced by the child in the relationship with the mother and the father, respectively.Such discrepancy is shown to become statistically significant when considering families with male children or families with children aged 7-12.Besides, it seems to be mostly linked to the lower security that the child perceives in respect of his/her parents.
Therefore, the discrepancy does not seem to affect the actual attachment perception within the parent-child relationship.Rather, it deals with the conviction that the parents have in being perceived by the children as more secure than they are in reality.
To further examine such aspect, we also calculated the discrepancy between the measures considering each dyad, respectively child-mother (CM-M2), child-father (CF-F2) and mother-father (M2-F2) for both the clinical and control group.This is to better understand the gap between the actual security perception of the child and the perception attributed to him/her by each parent.
As shown in Table 6, the only statistically significant difference is found in the child-father relationship (p = .017).The discrepancy is higher in the clinical group and, as already revealed by the standard scores in each scale (see Table 2), is mostly due to the low child's perception of secure attachment in respect with the father's attribution.

CONCLUSION
Our initial hypothesis that the neurological illness is associated to higher discrepancy in perceiving a secure attachment relationship inside nuclear families has partially been confirmed.Indeed, data show a statistically significant difference only among families of the clinical group with male children and with children from age 7 to 12 years.In this regard, previous studies indicated that gender may play a role in the manifestation of infant attachment behavior patterns in high-risk samples, as well as in clinical situations (Carlson, Cicchetti, Barnett, & Braunwald, 1989;Lyons-Ruth, Bronfman, & Parsons, 1999).In more detail, research shows a gender-related tendency for insecure boys to engage in more aggressive and self-referential behavior and for insecure girls to attempt to please others.Indeed, boys tend to display fight or flight responses to threat while females are more likely to display affiliative "tend or befriend" responses when exposed to severe stressor, such as illness experience (Taylor et al., 2000;Turner, 1991).This could explain the higher discrepancy we found in perceived attachment security within the families with male children of our clinical sample.With regard to age, we can hypothesize that younger children (7-12 years old) could be more affected by the quality of attachment relationships than adolescents (13-17 years old) who are more likely to gain in autonomy, perspective-taking skills, and new relationship experiences, thus having the opportunity to reconceptualize past attachment experiences (Allen & Land 1999;Bowlby, 1988).In addition, since children with neurological problems are generally diagnosed quite early, it is possible that parents of younger children could have spent a lower deal of time after their child's diagnosis, compared to parents of adolescents.This could have affected parents' resolution of their child's diagnosis, regarded as a significant predictor of child's attachment security (Walsh, 2003).Indeed, several studies on mothers of children with both cerebral palsy and epilepsy (Barnett et al., 1999;Morog, 1997;Walsh, 2003) demonstrated that the lack of resolution of their child's diagnosis was related to insecure attachment in the child and a non-autonomous state of mind with respect to attachment in the mother.Therefore, deal of time spent after child's diagnosis could be an useful variable to take into account in further research, in order to test child's age-related differences regarding discrepancy in perceiving secure attachments within nuclear families.
For an exploratory study such as ours, the results obtained could lead to further research on a bigger sample that could provide information that could be generalized.With specific regards to the child-father relationship, data suggest a strong gap between the security in attachment perceived by children with neurological illness and the security in attachment perception that fathers attribute to them.According to attachment theory (Bowlby, 1969), raising a child with special needs, although quite stressful for caregivers, may be more likely to result in considerable parental devotion to vulnerable children.Indeed, mothers of children with neurological problems tend to become overprotective, overinvolved, and solicitous because they perceive their child to be helpless, in constant pain, or in medical danger (Barnett et al., 2011).This could lead to a strong mother-child relationship, as a dual pair excluding or ignoring the figure of father, thus explaining the higher discrepancy found in perceived attachment security between child and father.
Nevertheless, it is interesting to have data that deserve investigation and that could be explored in the future while taking more variables into account.We think it is could be useful to repeat such analysis on a wider and varied sample that takes into consideration important variables that this research has not been able to analyze.In this way, it could be possible to evaluate the type of rehabilitation that the children with neurological illnesses utilize, keeping in mind the impact that a hospitalization could have on the nuclear family with respect to a treatment of the Day Hospital type.The Serbian public health system uses, in fact, hospitalization of the child with the mother, something that our previous study (Langher, Kourkoutas, Scurci, & Tolve, 2010) demonstrated to be very influential on attachment perception.
In conclusion, we think that research on attachment within nuclear families should increase, going beyond the usual dyadic relationships and providing a more complex interpretative framework on the issue.

Table 1 .
Characteristics of clinical and control subjects

Table 2 .
Scores of each scale/subscale in the clinical and control group

Table 3 .
Comparison of the discrepancy indexes between the control and clinical group (family triads)

Table 4 .
Analysis of the discrepancy index CP-M2-F2 between the clinical and control group by gender

Table 5 .
Analysis of the discrepancy index CP-M2-F2 between the clinical and control group by age range

Table 6 .
Comparison of the discrepancy indexes between the control and clinical group (family dyads)