Attachment

Below is an article authored by one of our own IAC staff:

Fostering the Parent-Child Attachment Relationship
by Mary Chesney, R.N, C.P.N.P., M.S.

Trends in adoption have changed significantly over the past two decades. Prior to 1990, most internationally adopted children came to their families as young infants, and many of these infants lived with foster families or in small orphanage settings prior to their adoption. Over the past ten years, the trend in international adoption has shifted dramatically. Now, a majority of families adopt children from countries where children reside for the first one to two years or more of life within institutional care. This change has brought with it increasing parental questions and concerns about parent-child attachment. The purposes of this paper are to: (1) provide a developmental overview of the typical attachment process in infants who are with their parents from birth in order to better understand parent-child attachment process in the newly adopted child; (2) discuss the pre-adoption orphanage environment that may affect the newly adopted child's reaction to family life; and (3) provide practical suggestions for helping children transition into family life and their relationship with parents.

Normative Attachment Theory

According to renowned attachment theorist John Bowlby (1969), the attachment system evolved so that vulnerable human infants and their primary caregivers would remain in close proximity to each other to ensure the infants' survival. As described by Bowlby (1969), the attachment system is an organized, goal-directed set of behaviors. The system is a developmental process that progresses in phases, from an infant's being indiscriminate (caregivers are interchangeable) to the infant's being discriminate (infant wants only a preferred caregiver).

During the first three months, the infant is aroused by physiological need such as hunger, fatigue, or need of warmth or comfort. Aroused, the infant cries, which signals the caregiver. Hopefully, a sensitive caregiver reads and interprets the infant's cues and meets the infant's specific need in a timely manner. This causes the infant to feel satisfied. In an optimal home setting, this cycle (infant need/satisfaction cycle) is repeated continuously during the infant's first few months of life. Initially, the need/satisfaction cycle is driven by basic physical needs. Throughout this often-repeated pattern, the sensitive caregiver externally provides physiologic regulation of the infant's arousal state (Carlson, Sampson, & Sroufe, 2003). In other words, since the upset infant cannot calm himself, the caregiver helps him calm down by not only meeting the specific need, but also providing nurturing gestures such as holding, cuddling or rocking. Advancing the work of John Bowlby, Mary Ainsworth and colleagues demonstrated in their research that caregiver sensitivity to infant cues during the first three months of the infant's life has a fair amount of predictability for the quality of the infant-caregiver relationship by 12 months of age (Ainsworth, Blehar, Waters, & Wall, 1978)

During the next three months (3 to 6 months), the infant begins to be aroused not only by physiological needs, but also by needs for social interchange with caregivers. The infant now may actively elicit emotional response from the caregiver. Toward the end of this phase, the infant begins to demonstrate a preference for the caregiver(s) (attachment figure) (Bowlby, 1969). The infant learns to trust in the caregiver and prefer the caregiver.

The next phase (6 to 9 months) is marked by the infant's emerging capacity for mobility. Through his or her ability to move about, reach and grasp, the infant is able to actively seek proximity or closeness to the preferred attachment figure. There is also an emerging quality of reciprocity (social give and take) in the infant's interaction with the attachment figure (Bowlby, 1969).

During the last portion of the infant's first year (9 to 12 months), the full set of attachment behaviors become operational. The infant begins to display exploratory activities; in novel or strange situations, the infant seeks proximity to the preferred attachment figure as a secure base; and the infant develops a wary/fearful behavior toward strange things including strange persons (stranger anxiety) (Bowlby, 1969).

Why Is Attachment So Important?

Attachment may serve as a prototype for future relationships. The attachment process may help humans shape their view of others and themselves. Bretherton (1985) theorized that through the attachment process, the infant organizes an internal working model of the attachment figure from which a working model of self is derived. When reared in an optimal family environment with sensitive, consistent caregivers, the infant learns that the preferred attachment figures can be trusted. Further, the infant begins to see the self as being lovable and competent to elicit and obtain necessary physical, social and emotional resources for living a happy life.

What Happens for Infants in Institutions?

For more than five decades, researchers have emphasized the negative physical and emotional effects of institutional rearing on children (Ames, 1997; Hodges & Tizard, 1988; Provence & Lipton, 1962; Tizard & Hodges, 1978). By reviewing the infant's need/gratification cycle as it might occur within a large institutional setting, some of the problems for infants within institutions become apparent.

During the first three months of life, while the infant may be aroused by a physical need such as hunger, fatigue, or need of warmth or comfort, an adult may not be available to quickly meet the infant's need. Orphanages typically have poor caregiver-to-child ratios, with one caregiver trying to meet the needs of numerous infants. Additionally, in order to save time and demands on the caregiver, the care that is provided is often done so in a rapid and routine manner, leaving little time or opportunity to individualize care as needed by the infant.

During the next phase of development, infants are aroused by the need for social interaction as well as physical needs. Within orphanage settings, infant needs are often met inconsistently by any number of providers in a routinized, non-individualized manner. There is little time for playful or nurturing interaction between the infant and a consistent caregiver, making it difficult for infants to develop any kind of meaningful attachment pattern within the institutional setting.

Based on Bretherton's (1985) working model of self, it is possible that for many infants raised in institutional settings, there is little opportunity to develop trust in a preferred attachment figure and little opportunity to develop a sense of self-worth and mastery within the world. Infants whose needs go repeatedly unmet or are unsatisfactorily met must learn to either rely on themselves or turn to any readily available adult for attention, which, in part, may help to explain the indiscriminately friendly behavior often seen in institutionalized children (see website section on Indiscriminate Friendliness). This indiscriminately friendly behavior may be a coping mechanism that helps the infant obtain needed human interaction.

For children spending the first 9 to 12 months in institutional care, it is unlikely that a meaningful and secure attachment relationship is ever established with a preferred provider. If there is a preferred provider, given the high children-to-childcare provider ratios typically found in institutions, it is not likely that the provider is able to always meet the child's needs in a timely, consistent, or individualized manner, leading to an insecure attachment pattern at best.

Fostering a Healthy Attachment Relationship with the Adopted Child

Ainsworth and colleagues (1978) presented several attachment system considerations that are particularly important when discussing the attachment process in adopted, previously institutionalized children. First, they emphasized that the attachment process, as described by Bowlby, is a developmental process occurring in stages over time. As with other developmental processes, development of the attachment process can be delayed. Although most family-reared children will develop a preferred attachment figure between 6 and 9 months of age, children deprived of adequate primary caregiver interaction early in life may be delayed in developing a preferred attachment figure (Ainsworth et al., 1978). In other words, the good news for the orphanage-reared child, deprived of primary caregiver/parental interaction, is that once he or she is placed in a nurturing family environment, the attachment process may begin. It is important to remember that the attachment of an adopted child to an adoptive parent does not occur as "a one-time event" but as a process that unfolds over time. It is also important to note that a child's previous experiences may influence how he or she reacts to new experiences; if the child experienced an insecure attachment with a provider in the orphanage, or repeatedly had needs ignored, it may take somewhat longer for the child to forge a trusting relationship within his or her new adoptive family.

Through many years of experience, the staff at the International Adoption Clinic has found that families can shape their newly adopted child's environment in ways that maximize time and interaction with parents. Children who have spent the first one, two or more years in an orphanage do not have any conceptualization of what it means to be part of a family. They may not associate the reception of food, nurture and comfort with any type of meaningful social interchange. To the previously institutionalized child, at first parents may look like any other caregivers within the child's environment. For the newly arrived adopted child who is presented with a daily continuous stream of well-wishing extended family, friends, neighbors and babysitters, it may be confusing to distinguish parents from other caregivers. Likewise, it may be difficult for adoptive parents to find quality one-on-one time to meaningfully interact with their child if too many social demands are placed on the newly adoptive family. Frequently, extended family and friends are anxious to be part of the adopted child's life. Unknowingly, they may view the child's indiscriminately friendly overtures as charming and cute, or reinforce behaviors that may delay the child's ability to develop a needed preference for parents. The best gifts extended family members and friends can give the newly adopted child is the gift of understanding how foundational and vital a close relationship with parents is for the child and the gift of supporting the adoptive parents and child in this effort. For these reasons, the International Adoption Clinic staff has developed a number of practical recommendations to be implemented by the adoptive family during the first 6 to 9 months after adoption.

Recommendations for the First 6 to 9 Months

Our list of recommendations is based on the collective years of experience of our team of adoption health care specialists and has evolved over time. In presenting these recommendations, I would like to acknowledge the collaborative contributions of my clinic colleagues, Dana Johnson, MD, PhD, Angela Sidler, MD, Stacene Maroushek, MD, Kay Dole, OTR, Sandy Iverson, RN, CNP, Mary Jo Spencer, RN, CNP, and Maria Kroupina, PhD. "

• We recommend a low-keyed arrival scene as you return home from your child's country of origin. It is usually best to avoid having a large crowd greet you. Your child should stay in your arms and should not be passed to others.
• Develop daily routines and rituals, and stick to them as much as possible. In keeping mealtimes, bedtimes and playtimes consistent, your child will begin to feel that each day has a predictability and structure to it. This is comforting for the child who is experiencing a period of incredible change and transition from orphanage to adoptive family.
• We recommend that parents, as much as possible, be the only persons to feed, change, bathe, dress, rock to sleep, or comfort their child. We think it is helpful for your newly adopted child to practice having needs consistently met by you, the parent.
• When extended family members or friends bring gifts for your child, we recommend that you have your child sit with you and that you hand the gift to your child or assist your child in opening the gift. You may want to say something like "Look, Annie. Grandma brought you a present. You may open it now."
• In the beginning, you may want to advise relatives and friends ahead of time that they should ask your permission to pick up your child or do an activity with your child. Each time they ask permission, your child is hearing them reference you as the important decision-maker for activities that involve your child. This may provide your child with practice in referencing you before embarking on a new experience.
• In large group gatherings, like adoption shower parties, let guests know ahead of time that you will be holding your child and that you will not be passing your child around from person to person. Overall, we advise avoiding large group gatherings during your child's first few months home. A previously institutionalized child does not need trips to Disneyworld or a day of shopping at the mall. What he or she needs more than anything is lots of concentrated one-on-one time with a warm, loving and sensitive parent.
• Spend as much one-on-one time with your child as possible. Your child does not need to be surrounded by lots of toys. In fact, being surrounded by too many toys and an overly stimulating environment may be overwhelming. Instead, choose one or two toys and get down on the floor with your child, and play with the toys in an interactive manner with your child. Use lots of facial expressions and face-to-face gestures like peek-a-boo or rubbing noses together. Watch your child for cues that he or she may be getting overwhelmed or tired, and then switch to a soothing, comforting activity such as rocking your child.

Sometimes, despite undertaking the above recommendations, parents may notice their child is having a difficult time in developing an appropriate attachment relationship. If you feel you and your child are experiencing difficulties, you may want to seek the help of a trusted professional, hopefully someone with lots of experience in working with internationally adopted children. Unfortunately, a flurry of mass media reports has highlighted problems with a number of "attachment therapists" who are recommending therapies that are not only untried and unproven, but may be potentially dangerous or lethal. We at the International Adoption Clinic encourage parents to seek reputable therapists. If a treatment or therapy is recommended for your child that you, as a parent, feel is abusive or questionable, we urge you to trust your instincts and not condone or allow such treatment. We encourage you to seek a second opinion from a trusted and experienced physician, nurse practitioner or child psychologist.

References

Ainsworth, M.D.S., Blehar, M.C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.

Ames, E.W. (1997). The development of Romanian orphanage children adopted to Canada. Burnaby, BC, Canada: Simon Fraser University.

Bowlby, J. (1969). Attachment and loss: Volume I: Attachment. New York: Basic Books.

Bretherton, I. (1985). Attachment theory: Retrospect and prospect. Growing points in attachment theory and research. Monographs of the Society for Research in Child Development, 50 (1-2, Serial No. 209).

Carlson, E.A., Sampson, M.C., & Sroufe, L.A. (2003). Implications of attachment theory and research for developmental-behavioral pediatrics. Developmental and Behavioral Pediatrics, 24, 364-379.

Chesney, M. (2004). Indiscriminate friendliness. Retrieved December 16, 2004, from www.peds.umn.edu/iac/for_families/transitions/indiscriminate friendliness.html.

Hodges, J., & Tizard, B. (1989). IQ and behavioural adjustment of ex-institutionalized adolescents. Journal of Child Psychology and Psychiatry, 30, 53-75.

Provence, S., & Lipton, R. (1962). Infants in institutions: A comparison of their development with family-reared infants during the first year of life. New York: International Universities Press, Inc.

Tizard, B., & Hodges, B. (1978). The effect of early institutional rearing on the development of eight year old children. Journal of Child Psychology and Psychiatry, 19, 99-117.

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