Notes on Attachment
August 25th, 2008 |By Arthur Becker-Weidman, Ph.D.
Click here to contact Arthur and/or see his GoodTherapy.org Profile
Attachment is the base upon which emotional health, social relationships, and one’s worldview are built. The ability to trust, and form reciprocal relationships, will affect the emotional health, security, and safety of the child, as well as the child’s development and future inter-personal relationships. The child with disordered attachment may be impulsive, doing whatever the child feels like, with no regard for others. This child may be unable to feel remorse for wrongdoings, mainly because the child is unable to internalize right and wrong. The child may tell you that something is wrong, but that will not stop the child from doing it.
Children, who are adopted after the age of six months or so, may be at risk for attachment problems. Normal attachment develops during the child’s first few years of life. Problems with the mother-child relationship during that time, or breaks in the consistent caregiver-child relationship, prevent attachment from developing normally. There are a wide range of attachment problems that result in varying degrees of emotional disturbance in the child. The severity of attachment disorder seems to result from the number of breaks in the bonding cycle, and the extent of the child’s emotional vulnerability. Emotional vulnerability can be affected by a variety of factors including: genetic factors, pre-natal development including maternal drinking and drug abuse, pre-natal nutrition, and stress, fetal alcohol syndrome and fetal alcohol effect, temperament, birth parent history of mental illness (schizophrenia, manic depressive illness, etc.) One thing is certain; if an infant’s needs are not met consistently, in a loving, nurturing way, attachment will not occur normally.
So how can we tell the difference between a child who “looks” attached, and a child who really is making a healthy, secure attachment? This question becomes important for adoptive families, because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone ”mom” or “dad,” snuggles, cuddles, and says ”I love you,” does not mean that the child is attached, or even attaching. Saying, “I love you”, and knowing what that really feels like, can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Normal attachment takes a couple of years of cycling through mutually positive interactions. The child learns that the child is loved, and can love in return. The parent’s give love, and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner, and that the child “belongs” to his family, and they to him. Positive interaction. Trust. Claiming. Reciprocity (the mutual meeting of needs, give and take) these must be consistently present for an extended period of time, for healthy, secure attachment to take place. It is through these elements, that a child learns how to love, and how to accept love.
Older adopted children need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of their new household’s routines, and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child’s past may start to surface. Some start to get labels like, “manipulative,” “superficial,” “sneaky”. Sooner or later the family may decide that this kid is all “take” and no “give”. The child “gives” only when it is to his own benefit. The child can seem to be very selfish and controlling. On the inside, this child is filled with anxiety and fear. The child has not developed the self-esteem that comes with feeling a valued, contributing, member of a family. The child cares little about pleasing others, since his relationship with them is quite superficial.
First Year of Life Cycle
The first year is a year of needs. When the infant has a need, it initiates attachment behavior in order to summon a nurturing response from the infant’s attachment figure. The need-gratifying response usually includes touch, eye contact, movement, smiles, and lactose. When gratification occurs, trust is built. This cycle occurs hundreds of times a week, and thousands of times in the first year. From this relationship, a sychronicity develops between parent and child. The caregiver develops a greater awareness of their child and learns just how to respond. The child develops good cause/effect thinking, feels powerful, trusts others, shows exploratory behavior, and develops empathy and a conscience.
When the first year of life cycle undermined, and the needs of the child are not met, mistrust begins to define the perspective of the child and anxious attachment results. The cycle can become undermined or broken for many reasons:
- Multiple disruptions in caregiving.
- Post-partum depression.
- Hospitalization of the child causing separation from the parent and/or unrelieved pain.
- Parents who are attachment disordered, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship.
- Genetic factors.
- Pervasive developmental disorders.
- Caregivers whose attachment needs are not met, leading to overload and lack of awareness of the infants needs.
The child naturally develops mistrust and shuts down effective attachment behavior. The developmental stages following the first year continue to be distorted and/or retarded and various symptoms emerge, such as (note this listing is NOT a diagnostic criteria. Diagnoses can only be made by trained and licensed mental health professionals) :
- Superficially engaging and charming. [phoniness]
- Lack of eye contact.
- Indiscriminately affectionate with strangers.
- Not affectionate on parental terms.
- Destructive to self, others, and material things.
- Cruelty to animals.
- Primary process lying (lying in the face of the obvious*)
- Low impulse control.
- Learning lags.
- Lack of cause/effect thinking.
- Lack of conscience.
- Abnormal eating patterns.
- Poor peer relationships.
- Preoccupation with fire and/or gore.
- Persistent nonsense questions and chatter.
- Inappropriately demanding and clingy.
- Abnormal speech patterns.
- Sexually inappropriate.
Parenting
Parenting children with attachment difficulties is a job that requires a great deal of patience, understanding, courage, solid support systems and personal fortitude. Children with attachment difficulties rarely and only superficially return love. Therapists, teachers, child protective services, and even spouses often do not understand the challenge and deception an AD child displays toward an adoptive/foster parent in charge of primary care. Often times the child will project the greatest amount of pathology towards the mother-figure in an attempt to make the world believe that if the mother was not so harsh and controlling, the child would be as lovable as it superficially displays.
Therapists often times are introduced to AD cases witnessing a burned-out parent in their office who is angry, resentful, and full of blame toward their child. Unfortunately the therapist may react by thinking (and sometimes saying) “if this mom would just lighten up on this kid, she would not have so many problems’.” This can lead the therapist to scolding the parent much in the same way the therapist experiences the parent scolding the child. Many well intentioned, but naive, health care workers believe that “all this kid needs is love” and end up creating an alliance with the child against the parents that furthers the family getting the help they desperately need.
The basic purpose of attachment therapy is to help the child resolve a dysfunctional attachment. The goal is to help the child bond to the parents and to resolve their fear of loving and being loved. A high percentage of the children that I see are foster or adopted children who have lived in one or more foster homes and have suffered from loss, neglect and/or abuse. Often the children come with a diagnosis of Oppositional Defiant Disorder [ODD] or Conduct Disorder [CD]. Many have a secondary diagnosis of Attention-Deficit Hyperactivity Disorder. The child’s symptoms could also be understood as a Post Traumatic Stress Disorder or Depression stemming from a delayed grief reaction in response to one or more significant losses early in childhood. Whatever the diagnosis is, it is important that the developmental history receives the consideration required to provide the appropriate treatment. Dyadic Developmental Psychotherapy is an evidence-based treatment that is effective for treatment of Reactive Attachment Disorder and Complex Trauma. There have been two empirical studies published in professional peer-reviewed journals regarding the efficacy of this treatment.
Because attachment is developed in the first years of life, often times the trauma driving the child’s pathology is pre-verbal. The child needs a solid educational component of treatment for the child to understand what force is driving the feelings and controlling the child’s behavior. The parents also need the education and understanding that the child’s behavior is not caused from their parenting, but from past traumas. From this base then, new parenting interventions can be designed from a cooperative relationship to fit a child with special needs.
A major dynamic in the treatment, is the affective work needed to heal the emotional wounds that drives these children’s behavior. A corrective emotional experience is orchestrated allowing the child to express these feelings, recognize and recall them and identify the events and the people involved. In essence, the child going through this experience with their parents allows for resolution of old pathological emotions while simultaneously creating powerful new bonds. As with any good trauma therapy, revisiting the trauma in order to integrate the fragmented and overwhelming experiences is crucial for healing. The revisiting must be done in a sensitive and titrated manner to avoid dysregulating the client.
©Copyright 2008 by Arthur Becker-Weidman, Ph.D.. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Arthur and/or see his GoodTherapy.org Profile
August 26th, 2008 at 3:00 am
I have a friend who first became a foster parent and then ended up adopting one of the babies that was in her custody. And even though that child has been with them from a very early age she still just seems to need more love and care than her own biological children do. There is certainly something that happens even in infancy where a child learns how to love and to be loved in return and I watch as this mom and family struggle on a daily basis to help the adopted child find the right balance and for them all to learn what it means to be a loving and reciprocal family.
August 26th, 2008 at 6:14 am
Can anyone provide any empirical evidence for that list of “attachment disorder” symptoms?
Also, i’ve always wanted to know the actual source of the “first-year cycle” and “second-year cycle”. They resemble some combination of Freud, the ego psychologists, and Wilhelm Reich, but no citation is ever given in the various holding therapy-related publications that refer to them. They have nothing to do with any empirical work in developmental psychology.
Can anyone help me on these points?
August 26th, 2008 at 10:02 am
Hi Jean, I’m not an expert on childhood attachment problems, but I can tell you that if you ask nearly any experienced clinician about the symptoms which Art lists above, he or she will tell you that these are generally agreed upon, blatantly evident behavioral / emotional reactions to attachment disturbance. Of course, due to differences in many factors, such as genetics, temperament, and experience, not all children are going to present similarly, given similar attachment disturbance. I’m guessing that there is probably loads and loads of empirical evidence for these symptoms. Would anyone with more information than I want to chime in and answer Jean’s question? Noah
August 26th, 2008 at 12:10 pm
No, they aren’t generally agreed upon, Noah. Read Everett Waters, read Zeanah, read whom you like (outside of holding therapists), you will not see those characteristics described. Of course there are severely disturbed kids who have such symptoms, but attachment is not the issue that causes them.
August 26th, 2008 at 12:40 pm
Jasmine,
You are very observant and correct. Your comments are excellent, cogent, and valuable here. Those first few years are crucial in the development of a pattern of attachment. This is the basis for the capacity to engage in authentic emotionally meaningful relationships without undue distortions, anger, or disturbance. It requires parents who are able to engage in the concordant intersubjective sharing of experience (shared emotion (or attunement), shared attention, and shared attention). It requires sensitive and responsive and reflective parenting.
Your friends may find the following texts quite helpful:
Creating Capacity for Attachment by Arthur Becker-Weidman, Ph.D., & Deborah Shell, (2005) Wood N Barnes, Oklahoma City, OK.
Building the Bonds of Attachment, 2nd Ed., by Daniel Hughes, Ph.D., 2007.
If your friends are having difficulty, it is very important that they get appropriate support and treatment, if indicated. Dyadic Developmental Psychotherapy is an evidence-based and effective treatment for families with children who have trauma-attachment disorders, developed by a group of licensed mental health professionals and researchers with substantial experience in this area. Before beginning any treatment, it is very important to get a thorough and comprehensive evaluation so that the underlying issues are identified and not merely surface symptoms, which can have various causes and require different treatments.
Regards…I hope you will continue to contribute here. Your comments are most valuable.
August 26th, 2008 at 1:54 pm
With all due respect Jean I can tell you that, yes in fact, the symptoms that Art describes are often a part of attachment disturbance. I am somewhat familiar with Zeanah’s work and it would seem to support Art’s list of attachment disturbance symptoms. But, as I’ve said previously, let’s invite the experts on the subject of attachment to comment about attachment and to answer your questions. You and I are clearly not experts on the subject of attachment.
You write in your comment, “Of course there are severely disturbed kids who have such symptoms, but attachment is not the issue that causes them.” I am frankly and completely dumbfounded by such a misinformed and false generalization. Furthermore, for you to associate Art’s work with “Voodoo Science” (I later removed this statement and a number of others made by Jean) is truly an act of misinformation and potential slander that is not tolerated on this blog. Please state your facts accurately or I will have no choice but to moderate your comments in defense of truth and in protection of consumers who might be influenced by such nonsensical statements. You have been given fair warning.
For more information on our Comment Policy, please see http://www.goodtherapy.org/custom/blog/terms-and-conditions-of-use/
Noah Rubinstein, LMFT
Executive Director
August 26th, 2008 at 2:10 pm
Actually Jean, on second thought the most appropriate action (based on our Terms and Conditions) at this point would warrant me to either delete your comment in full or edit out the slander. I will first attempt to remove the slander and see if it is possible to keep the rest of your comment intact.
If you don’t like the results of my edit, feel free to send me an updated comment without slander or request that I delete the comment in full and I will do so.
Regards,
Noah
August 27th, 2008 at 2:59 am
Wow! I had no idea there was such debate over this particular issue. I have been a classroom teacher and guidance counselor for many years and while this may not qualify me to make a diagnosis, I have certainly met students and families over the years where this is clearly a problem. This is especially true in cases of not being able to identify cause /effect relationaships even on a most simplistic level as well as learning difficulties and behavior problems. While I know that there are those who will say that this may not have anything to do with attachement issues, I think that for many students this is actually the case. When you meet with families you get a sense of the familial relationships and know when there is more going on beneath the surface than meets the eye. I know this may be reaching for some people but I think that clearly there can be a realtionship between these issues and I am glad that this forum has given smeone the voice to bring this up. Thanks!
August 27th, 2008 at 8:16 am
Dear Christine,
As a professional, you have a lot of real and direct experience with this topic. I don’t think there is any real debate over this particular issue among actual professionals who have training and experience in this area.
In any event, your comments are right on target here. Most of the current writing and research in infant mental health and related topics of treatment, trauma, and behavioral problems focus on attachment, attachment theory, and parent-child relationships.
A wonderful book you may find helpful is
Attachment in the Classroom by Heather Geddes. It is written by an educator. There is another great reference too, but I don’t have that right at my finger tips now, but will post it later for you.
regards.
Art
August 27th, 2008 at 8:31 am
But, Christine, don’t you suppose that the inability to relate cause and effect might influence a child’s ability to form an attachment, just as well as the events being the other way around? Or that there may be one or more other factors that influence both?
In any case, how could you tell from behavior that a person can’t relate cause and effect? Would this mean that someone couldn’t learn to open a door by turning a knob? Or do you really mean that the child gets punished a lot, but still misbehaves? If it’s the latter, that could have a lot of explanations other than a cause-and-effect problem.
I think one of the difficultiess here is that people who have made this claim about cause-and-effect problems have based their thinking on Piaget’s outmoded description of the development of that kind of thinking, whereas modern infant development research shows that the capacity to make some cause-and-effect connections is already present at a few months of age. The result of thinking that children can really lack that kind of ability is an unfortunate focus on what the child can or cannot do, rather than on the adult behaviors (e.g. punishment) that may be influential.
Attachment is only one of the many variables that combine to determine the child’s developing characteristics, and we shouldn’t try to make it carry more weight than it’s capable of. It’s important to avoid “criterion creep”– the extension of a concept or a diagnosis to include a lot more than it was ever meant to handle. I believe criterion creep is happening when we begin to hear about “attachment disorders” outside the usual evaluative or diagnostic schemes.
August 27th, 2008 at 1:20 pm
Dear Christine,
I have those references now and hope that they will be helpful to you.
In reading your comments I see that you made a rather astute observation about problems with cause-effect thinking that stem from very early difficulties in the parent-child relationship. As a professional you know from your experience, and as any licensed mental health professional with expertise in this area knows, it is through the early parent-child relationship and attachment that the beginnings of cause-effect thinking develop, as my article describes (you can also look at Infant Mental Health… for more technical details). Bowlby describes this process quite well, as do some other professional researchers with expertise in actually conducting such research in these matters such as Mary Ainsworth, Mary Main, Mary Dozier, etc., and as is amply described in the texts below.
1. Geedes, Healther, (2006), Attachment in the Classroom, Worth Publishing, London.
2. Carnes, Kate, & Stanway, Chris, (2007), Learn the child: helping looked after children to learn. A good practice guide for social workers, careers and teachers. British Association for Adoption & Fostering (BAAF), London.
I think that you will find that these references will be quite helpful in your work. They describe the importance of attachment as a central organizing principle in child development and as a major factor in determining a child’s development and functioning in the classroom. As I mentioned in a previous post, these books are written by educators and professionals and so the authors understands the nature of your work, are professionals like you are, and have real training, licensure, and experience relevant to your work.
I hope you find the texts of use to you and that you will continue to contribute to this site; your comments have been quite informative, knowledgeable, based in real experience and understanding, and valuable.
Thanks.
Art
August 28th, 2008 at 9:48 am
Thanks so much for the guidance and resources. It is sometimes so frustrating to not know where to turn to help a student when there is obviously trouble at home and you feel like you are a real lifeline for a student, and sometimes the only lifeline you feel they might have at this point in time. I will certainly look at all of this and hopefully this can help me grow not only as a teacher but one who also struggles and desires to know and understand the lives and emotions of her students beyond that which is sometimes just a small piece reflected in the classroom and at school. Thanks.
August 30th, 2008 at 3:00 am
Do you think it is possible that a child can be born without the ability to form thes attachment bonds? Even if everything was done right during pregnancy and child rearing?
August 30th, 2008 at 8:56 am
Dear Gayle,
Thank you for that terrific question. My response highlights the importance of looking at causes and not symptoms since we treat causes not merely surface symptoms. The quick answer to your question is a “certainly, yes.” For an extreme example of that one can look at children with severe Autism. In these children the capacity to form emotionally meaningful, cooperative, responsive, and collaborative interpersonal relationships is quite impaired and their “attachment bond,” is quite impaired…but having nothing to do with chronic early maltreatment within a care-giving relationship. Another example might be the child who is born with significant brain-damage to the right orbital frontal cortex.
regards,
Art
August 30th, 2008 at 9:30 am
Genetic factors and temperamental differences can make a difference to the ease with which a child forms a secure attachment to particular caregivers. Children with serious cognitive challenges may not display preferences for caregivers as early or noticeably as those with normal intelligence.
However, because attachment is essentially a set of attitudes, feelings, expectations, and behaviors toward other people, and because it is a very robust aspect of development, the idea that there is “no attachment” in an otherwise normally-developing child is difficult to accept. Even children who approach strangers rather than staying with familiar people are displaying their attitudes about human beings, although in a disordered way. A child with “no attachment” would respond to all people (including other children) in about the same way.
If by “no attachment” Gayle means no secure attachment or secure base behavior, as I said before, this might be more likely for some children than for others, because of temperamental factors (inborn, biologically-determined personality components). If she means a lack of obedience or affection to caregivers, these matters are related to many factors other than attachment.
There are unconventional practitioners who claim that some babies are born with great resistance to attachment and refuse to respond to their caregivers. This claim is mistaken, and I would hope that other contributors to goodtherapy would speak against it.
August 30th, 2008 at 12:32 pm
Those interested in the connection of attachment with autism may like to look at
Rutgers, A.H. etal. (2004). Autism and attachment: A meta-analytic review. Journal of Child Psychology and Psychiatry, Vol. 45(6), 1123-1134.
This article reports evidence of attachment behavior in autistic children.
August 31st, 2008 at 4:41 am
Gayle,
One other point. As any clinician who has training, licensure, and experience (or who has conducted actual research) in this area and with, say Autism, would point out, that children can have “no attachment” for a variety of reasons and that this can be one factor in Austism Spectrum Disorders. In fact, this category of no attachment of nonattached attachment disorder is described in the text below. Most practitioners who have real knowledge and experience will point to several very important texts such as:
Zeanah, C., (2005), The Handbook of Infant Mental Health, 2nd. Edition, Guilford Press, NY., among several others.
I hope this is helpful for you…and, of course, if you have other questions, do feel free to post here or to contact me directly. Your post was quite helpful.
Art
August 31st, 2008 at 7:18 am
Yes, clinicians refer to handbooks and their own experience, and scholars refer to that difficult-to-read basic research literature– which is why the best answers to important questions come from a combination of clinical and academic opinion. The use of this combination really defines evidence-based practice, doesn’t it? And isn’t it the intention of this blog to provide the best possible information?
August 31st, 2008 at 11:10 am
Dear Gayle,
One other point, if you’d like useful information. In addition to the seminal text I referred you to, which all those professionals familiar with this subject refer to, you might also want to look at The Diagnostic Classification of Mental Health and Developmental Disorders (2005) by the Zero to Three group.
Of course the first text is really the primary text in the field, edited by Dr. Zeanah and including scholars (clinician/researchers) of international renown who have real professional experience, training, and who have conducted research into these questions. You will find this material most useful if you want to explore your very good question in more depth.
regards,
Art
August 31st, 2008 at 12:25 pm
DC:0-3R is a good source for people who have been trained in its use, and looking at the two versions (1994 and 2005) gives an interesting view of the changing definitions of attachment disorders. For example, the 1994 DC:0-3 speaks of Reactive attachment disorder, but this term was removed in 2005.
Some researchers consider the possibility that children with symptoms of the inhibited form of RAD actually have anxiety disorders, and/or problems with regulation of emotion. These suggestions are especially notable when we consider that “attachment disorders” were originally– and not so long ago– equated with Failure to Thrive.
Thinking continues to change on this topic, and it is no wonder that people feel confused about it. However, for the sake of children and families, we need to be able to tolerate ambiguity, and to avoid the assumption that disorders of attachment are well understood, easily diagnosed, or all treatable by a specific intervention.
September 1st, 2008 at 6:42 am
Dear Christine,
Another good text for you as a teacher is:
Bomber, L., (2007) Inside I am Hurting: Practical strategies for supporting children with attachment difficulties in schools. Worth Publishing, London. It is a terrific book, written by an professional who is both a teacher and licensed therapist and researcher.
You might also want to look at:
Becker-Weidman, A., & Shell, D., (2005) Creating Capacity for Attachment, Wood N Barnes, Oklahoma City, OK, which describes Dyadic Developmental Psychotherapy, an evidence-based treatment with empirical support that is grounded in current thinking and research on the etiology and treatment of Complex Trauma or Developmental Trauma Disorder.
If you have other questions, let me know. I also have other information that may be useful to you. For several years now I have consulted monthly during the school term with a group of counselors from a regional BOCES program (BOCES stands for Board of Cooperative Educational Services). BOCES is an entity created to provide special education services for a regional group of school districts. The idea being that a school district may not be able to meet the specific needs of a limited number of children, but by pooling resources, the BOCES programs have sufficient numbers to provide pretty decent specialized services for children with severe emotional problems, Autism Spectrum Disorders, etc.
regards
Art
September 5th, 2008 at 3:48 am
I have been in clinical practice for over twenty years and my specialty is depression, anxiety, and trauma. In this period I have experienced many, many different perspectives, different theories, different evidence-based practices and always I prefer respectful dialogue and appreciation for another’s point of view, whether or not it agrees with mine. Evidence-based practice is as important to consider as the cogent, well-thought out analysis a clinician presents to explain effective treatment that is not supported by empirical studies. We are complex beings and our understanding of ourselves changes over the years. Criticism shuts down communication and sharing our respectives beliefs without it brings rich learning and equally important, warm connection to the process. I don’t often participate in online dialogue because my life is very busy off line. But I read these comments and was prompted to offer these thoughts and thank the Admin Staff for managing this site so that we all have a place to respectfully give to and receive of each other. Patti
September 19th, 2008 at 1:41 am
Hi, I am a parent of a 4 year old boy. I am worried that my reprimanding my son constantly might make him hate me.
September 22nd, 2008 at 6:59 pm
I have an MA and an EdS in counseling. I have been going through holding therapy for the last year with my therapist who has the proper credentialing and supervision. At 40 years of age, this is an extremely difficult task, yet from my own experience as a therapist, I know that this is something I must endure to be able to “feel” love, which I currrently don’t feel - at least not the way most people do. Can you please recommend a site for Adults who are going through holding therapy? I need to be able to connect with others who feel the same way as I do. Thank you.
September 23rd, 2008 at 2:51 am
Dear Karen,
You might want to look at the White Paper on Coercion at the Association for the Treatment and Training in the Attachment of Children (www.attach.org). Cradeling or being held by a caregiver/significant other in a collaborative and non-coercive manner can be a very therapuetic and engaging experience. Coercion and intrusive methods are not appropriate in any treatment. The only time forced holding or restraint is appropriate is in those very rare situations where a person is dysregulated, out of control, and about to hurt self or others.
I have some material about attachment that is relevant for adults on my website, http://www.center4familydevelop.com
regards
Art