Background to attachment theory

Attachment theory has arguably become a central framework in understanding development, across cultures and globally over the past 75 years (Holmes Reference Holmes2014). The impact of early attachment patterns and experiences has a profound effect on one’s physical and mental health throughout the lifespan. Examining and embedding a person’s attachment experience has become commonplace in the assessment and treatment of many forms of mental illness and is the cornerstone of attachment-based individual or family therapy. Based on the work of John Bowlby, a child psychiatrist and psychoanalyst in the mid-20th century, attachment theory holds that the earliest experiences set the foundations for subsequent interpersonal relationships, resilience, and self-worth (Bowlby Reference Bowlby1951). Specifically, a positive, nurturing, and attentive relationship with a primary caregiver sets a ‘secure base’ from which a child can explore and return to at times of stress or uncertainty, providing the optimal environment for child development. Commencing prenatally with expectation and preparation for the infant by the mother/caregiver, it continues into infancy and early childhood. Through the repetitive interactions of holding, handling, soothing, swaddling, and rocking, with the caregiver, the infant builds up experiences which become internalised and encoded and alongside cognitive development are manifest as internal working models or representations of the attachment. This template then, according to attachment theory, can influence how the individual experiences and perceives the wider world, engages in social relationships, and manages stress over their lifetime.

Bowlby developed a lifelong professional partnership with Mary Ainsworth, who through her observational and experimental research with infants and mothers, described patterns of infant attachment. Using what became known as the ‘Strange Situation procedure’, three patterns were described as secure, insecure-avoidant, and insecure-ambivalent (Ainsworth & Bell, Reference Ainsworth and Bell1970). Later, Main & Solomon (1986) described disorganised attachment which related to early experiences of serious maltreatment or trauma and of significant clinical relevance (Main & Solomon, Reference Main, Solomon, Yogman and Brazelton1986). Securely attached individuals are considered to develop and maintain healthy interpersonal relationships, showing effective parenting, good emotional regulation, and resilience in the face of adversity. By contrast, insecurely attached individuals show more emotional dysregulation, increased instability in relationships, experience challenges when faced with parenting, engage in increased risk-taking behaviour, and have poorer physical health. Path analysis now suggests transgenerational effects, where maternal adverse childhood experiences directly and indirectly impact child well-being through maternal insecure attachment styles (Cooke et al. Reference Cooke, Racine, Plamondon, Tough and Madigan2019).

The impact of war in developing the attachment theory construct

Much of Bowlby’s work resulted from his own personal experiences, the abrupt disruption of his bond with his nanny when sent to boarding school at the age of seven, and clinical observations working with children who were behaviourally disturbed (Holmes Reference Holmes2014). Bowlby found that the vast majority (86%) of youth with affectionless psychopathy had experienced maternal deprivation in their early childhood. Bowlby’s work was fuelled by living through two world wars – the First World War saw the loss of millions of lives; the Second World War saw the sheer brutality of the Holocaust, with 50–70 million lives lost, along with much displacement and disruption to children in Europe. In his role working with the British government, Bowlby emphasised the role of the mother in fostering development at a time when, through the impact of war, male role models and heads of households were absent, lost, or dead. The adverse impact on children separated from parents during the war further shaped his attachment theory and the salient role of the early child−caregiver relationship. In 1952, Bowlby prepared a report, ‘Maternal Care and Mental Health’ for the World Health Organization citing his own and othersʼ research in which he concluded that ‘the prolonged deprivation of the child of maternal care may have grave and far-reaching effects on his character and so on the whole of his future life’ (Bowlby Reference Bowlby1952).

Impact of war on attachment relationships and mental health in children

War affects children differently to adults, by virtue of their dependency on parental love, care, and protection (Santa Barbara Reference Santa Barbara2006). War impacts both directly and indirectly on the availability of nurturing care, often through the absence or actual death of a parent. Typically, the father is absent due to engagement in the military effort, and maternal attention turns to the basic needs of survival and subsistence of the family, seeking food, water, and refuge. The emotional availability of adults for children can also be impacted by associated illness or injury or later by depression and post-traumatic stress disorder (PTSD). Children may be placed in care away from their families, such as during WW2, where the ‘ordinary’ devotion to the child will not necessarily be met (Winnicott Reference Winnicott, Caldwell and Robinson1949). The more recent reality for a significant number of children where they lose all adult carers, the so-called ‘unaccompanied minors’ or ‘wounded child no surviving family’, can leave the child bereft without any attachment figures. There are also secondary impacts on children, such as the loss of health and educational infrastructure secondary to the destruction caused by war and conflict and the spending of lengthy periods in refugee camps, without adequate facilities and with lives on hold until the conflict resolves. Medical impacts include life-changing disabilities, such as amputation or neurological injuries, which require long-term rehabilitation and care, thus impacting on their potential being reached. Sexual violence is also perpetrated against children in times of war, leaving many with often invisible wounds that can negatively impact later intimate relationships, parenthood, and mental health.

Trauma may also affect individuals and families in other ways by impacting family atmosphere, values, and beliefs, reducing the capacity to emotionally attune or share, and affecting families’ relational scripts, codes, and histories; all of this can influence individual responses to trauma of family members (Punamaki et al. Reference Punamaki, Qouta and Peltonen2018). Added to this is the disruption of wider social support and infrastructure and access to basic needs of food, shelter, and healthcare.

There can be biological changes too, with the impact of conflict being woven into our biological construct. For example, it has been suggested that epigenetic changes could play a role in mental health following war. Epigenetic alterations are noted in genes regulating the hypothalamic–pituitary–adrenal (HPA) axis in survivors of childhood and adult trauma, potentially contributing to more enduring changes in the stress response (Ramo-Fernández et al. Reference Ramo-Fernández, Schneider, Wilker and Kolassa2015). It has long been established that dysregulation of the HPA axis plays a key role in the development of PTSD and other psychological impacts of war. Given that resilience to the development of PTSD is linked to the presence of secure attachments earlier in life, this can place those in war zones at further increased vulnerability.

Ongoing impact of conflict today

In spite of these serious impacts in conflict zones, the number of children affected globally has been increasing in recent years. A report by Save the Children in 2021 reported a 20% increase in 2020 in the numbers of children living amid lethal conflict, reaching almost 200 million, compared with 162 million a year earlier (Save the Children 2021). By 2022, the Uppsala Data Program report this number had climbed further to about 468 million children, or 1 in 6. At that time, the wars in Ethiopia and Ukraine were the primary contributors, and the data did not include the unanticipated death toll that has erupted following the Oct 7th Hamas attack on Israel and the subsequent war on Gaza. There are reports of the killing of 10 000 children in the conflict in Gaza to date (https://edition.cnn.com/middleeast/live-news/israel-hamas-war-gaza-news-01-17-24/h_257bdc236b13560cf82166ffb89b8a22). Of further note is that the rate of mental illness among conflict exposed populations is relatively high with a systematic review in 2019 reporting prevalence rates of mental disorders as approximately 1 in 5, higher than previously reported mean global prevalence rate of 1 in 14 (Charlson et al. Reference Charlson, van Ommeren, Flaxman, Cornett, Whiteford and Saxena2019).

Such ongoing wars and the associated humanitarian crisis have profound consequences at a global level, resulting from wide-scale population displacement, loss of life, disabilities, devastation of economies, and impact on social, educational, and healthcare structure of countries. Political and economic instability make it difficult to rebuild communities. In addition, recent wars have been depicted in real time through the availability of live streaming and social media technology which has allowed those of us fortunate enough not to be living through these experiences, to vicariously experience the suffering. While this provides us with an awareness of our responsibility to act for others, including children, it can also contribute to feelings of insecurity, reactivating old traumas and feelings of disappointment in humankind. Strong, united international efforts to decrease impact of war and conflict are needed, while being mindful of historical and ongoing trauma and prioritising immediate safety.

Just as Bowlby played a crucial role in advising the UK government in the post-war settlement, so too must the clinicians of today take up this mantle and advocate loudly to protect children and their families. A fundamental right, the right to life, for many children and their families is being breached. To stand by and allow these deaths and watch many more seriously maimed is unconscionable. In this editorial, we have highlighted how war impacts attachment for many children and how this will have transgenerational effects for many decades ahead. We argue that clinicians can be global leaders in this arena, influencing policies, and we have an ethical obligation to speak up on these issues.