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Facilitating Attachment - Attachment Difficulties and Attachment Disorder in Adopted Children
- Karleen Gribble, PhD Adjunct research fellow Uni Western Sydney Transcript of a presentation for the 8th Australian Adoption Conference. Attachment - what's it all about? Typically, we've thought about attachment in adoption in fairly vague terms, as the child's capacity to join with the adoptive family. But attachment means much more than that. Bowlby described attachment as the affectional tie between two people, beginning with the bond between the infant and mother. Every adopted child comes to her new family with attachment problems, simply by virtue of having lost her birth mother. And for many adopted children - especially older children, but some babies as well - there are additional factors of abuse, neglect, trauma or multiple losses which further interfere with attachment and can lead to attachment disorder - properly known as Reactive Attachment Disorder. There are a lot of misconceptions about just how easy it is for an adopted child to attach, and there's a lot of ignorance about what it looks like when things go wrong, and a child remains unattached. Let's talk about some theory to begin with. Our romantic notions of why babies need to be close and cosy with their mums began to get some scientific validation in the 1950s with the work of Harlow, Bowlby and Ainsworth. Harry Harlow, as some of you'll know, raised baby Rhesus monkeys in isolation with surrogate mothers. When given a choice between a hard wire "mother" who provided food (via a teat attached to a milk supply), and a soft, cloth-covered "mother" who provided no food, they preferred to cuddle up to the cloth mother. John Bowlby, who's regarded as the "father" of Attachment Theory studied attachment and separation behaviour in young children. Years of studying the infant-mother relationship in animals and humans led him to the conclusion that attachment is necessary for survival. Human babies are driven to be close to their mothers, especially in times of stress. In other words, babies need to be close to their mother to be safe - and they seek this closeness. (Please note here that I'm using "mother" in a generic sense - the role of the mother can be taken over by anyone involved in a regular care giving relationship). Mary Ainsworth's classic work involved using the "Strange Situation" scenario. When they were left alone in a room with their mother, well-adjusted young children would explore the room happily, returning to mum every so often for reassurance, and would immediately go to mum when a stranger entered the room. She called this having a "secure base" - mum is like a beacon which can orientate you and help you feel safe. Other children would cling to their mothers the whole time - their attachment was anxious, and they'd be afraid to leave mum to explore - and the others were disinterested in their mums and paid them little attention - they were barely or not attached. Over time, the developing child's experiences with her mother lead her to form internal representations of her mum and herself. If her experience is of this "secure-base" mum, secure and responsive, then she feels worthy, she has trust in her mother, and she begins to generalise those feelings to form a view of the whole world as a trustworthy place. But if she can't trust mum to give the responses she wants and needs, then she forms an opinion of herself as unworthy, that mum can't be trusted, and that the world is an untrustworthy place. Thus, this first, primary bond becomes an internal representation of how the child will go on to form relationships with the world. Now - if you can't trust anybody - then the world is a frightening place, one in which you can only trust yourself. The attachment experience is an essential developmental experience that needs to occur before the age of about 3. If it doesn't occur, or there's disruption of a developing attachment, what happens? Unable to trust others, the child avoids intimate relationships, and life becomes a struggle for control on his terms. His conscience doesn't develop properly, he can't internalise right and wrong. He lies and steals. He lacks empathy. He's angry all the time. He's charming with strangers and hostile toward his mother. Scientists have shown that in children whose early attachment relationships are disrupted, higher order thinking doesn't develop properly, and the structures in the brain that regulate emotion and mood are underdeveloped. This may lead to symptoms of hyperactivity that look like ADHD, and specific learning difficulties. It also causes poor cause-and-effect thinking. The brains of these children show many manifestations of the trauma response. In a sense, children who haven't attached, who've experienced abuse or neglect, have experienced significant trauma. Now, this can happen - typically - in a child whose caregiver is neglectful or abusive, but it can also sometimes happen with a loving caregiver, when the child experiences trauma or abuse from some other source. If the child's experience is of fear and betrayal of trust, of pain that her mother can't relieve, then that trusting attachment can be damaged. Symptoms of Reactive Attachment Disorder
Let's talk some more about how the attachment relationship starts. Science can tell us a lot about what babies are born expecting from life. So how do babies expect to be cared for? Babies are born expecting to be cared for by their biological mother. They recognise her through smell (her amniotic fluid smells much the same as her breast milk), through voice (from before birth) and sight. Babies give a specific "separation distress call" when they are separated from their mother. Thus babies know their mother from birth and recognise her loss. There is strong evidence that babies expect to be kept in close physical contact with their mother, suckling frequently to obtain food and sleeping with her. How do we know this? Babies, who are carried more, cry less. There's good reason to believe that the threshold for acceptable levels of crying in babies is set too high in Western societies - and that's because we're not used to carrying our babies and we get used to a lot of crying. Certainly, crying is known to have potentially serious negative affects on the newborn brain. Carrying a baby and moving around with them also provides proprioceptive-vestibular stimulation - that's stimulation of the movement & balance centres in our muscles, our inner ear & our brain - which fosters an environment that facilitates interaction between caregiver and child and results in increased maternal responsiveness and increased security of attachment. Skin to skin contact reduces the release of stress hormones in babies, reduces blood pressure and stabilises blood glucose levels. When babies are held in skin-to-skin contact with their mothers, their temperature, their breathing rate & their heart rate are regulated and stabilised. There is also strong scientific evidence that human babies are meant to suckle frequently. What tells us this? The composition of human milk is extremely low in fat and protein, similar to that of other mammals who carry their babies, which suckle constantly. Those whose milk is high in those factors suckle infrequently - they tend to be animals which leave their babies alone for long periods of time. Breastfeeding, as well as providing food for babies, results in calming, it reduces heart and metabolic rates and pain relief through the physical and social contact, and it also causes opiates to be released in the brain. Finally, there is some evidence that co-sleeping is expected. Keeping babies in close physical contact at night not only results in more frequent breastfeeding but also results in synchrony of sleep cycles and protects the infant against long periods of deep sleep that may contribute to SIDS. Thus, mothers act as external regulators of their child's physiology and emotions. The mother is the infant's habitat! So how does this affect the mother? As we've described, keeping a baby in close physical contact helps the mother to respond sensitively to her child and helps security of attachment. Skin to skin contact results in the release of the hormone oxytocin which is involved in the development of human maternal love and it may well influence care giving. Frequent breastfeeding also causes the release of the hormones oxytocin and prolactin in the mother (they're associated with mothering behaviour). The net effect of all this is that, breastfeeding mothers have decreased cortisol levels - their blood pressure is lower, they respond less to stress than non-breastfeeding women and from a psychological point of view are calmer and more interactive which may have a significant impact on the way in they care for their children. How can this information help us in caring for children post-adoption? While children born into their families may be able to thrive when parented in a way outside of this physiological norm, children who have already been badly hurt by maternal loss (which is all adopted children), early neglect, abuse or multiple placement (which is many of them), need parenting as close as possible to the norm in order to maximise healing. Here are some guidelines which we consider will promote attachment in young newly adopted children. Firstly, children should be kept in close physical contact with their primary caregiver and caregivers encouraged to carry children as much as possible. Carrying can increase the mother's sensitivity and provide opportunities for connection and attunement, as well as additional security. The Western alternative of a pram separates the child from their caregiver. Secondly,skin to skin contact through such activities as massage, co-bathing and swimming together will be helpful in providing pleasurable interaction, the release of oxytocin and potentially the regulatory effects described earlier. Thirdly, co-sleeping will assist in providing opportunity for physical closeness and responsive care through the night, and many adoptive parents find it helps with the sleep difficulties that are so common to newly adopted children. Fourthly, if the adoptive mother is able to breastfeed her child the mother will benefit from the hormonal influences, the child will benefit from the associated skin-to-skin contact, and hormonal and calming influences. Breastfeeding is intimate interaction over time and is thus helpful in building trust and attachment. Some children may take quite a while to feel comfortable with the closeness and intimacy of breastfeeding with an adoptive mother, yet others will actively seek breastfeeding. In addition, parents might consider feeding even an older child - by handfeeding or with a bottle, which can help to replicate somewhat the early expected experience of nurture through food. So, keep in mind that adoptive parents can still affect the physiology of their children in some, but perhaps not all of the ways that biological mothers do. It's also worth remembering that caring for an adopted child in such a close, intimate way can produce neurological and behavioural changes in the adoptive mother the same as those experienced by biological mothers. Remember that many children won't be comfortable with this level of intimacy at the time of placement. Whereas for a child cared for by the biological mother since birth, intimacy usually means security and comfort, for a child with a history of hurt in relationships, it's scary, even terrifying. The caregiver needs to be gently persistent with this closeness and responsive care giving. In dealing with specific behaviours it doesn't matter whether a behaviour is "developmentally normal" or not - with any sort of discipline, the caregiver always needs to handle it in a way that promotes closeness, rather than distance. Case StudiesLet's look at some case studies to see how we might apply these principles to adopted children and their families.
Attachment Therapy. Many children who have RAD have seen a number of therapists over the years. However conventional therapy has often proven ineffective. "These kids aren't reachable dynamically because there is no relational template, no 'other' in the psychic system, and unreachable behaviorally because they lack cause and effect thinking and can not generalize. They are profoundly over aroused at the level of the CNS and although they do not, actually cannot, talk of being terrified, they are - They have no capacity for empathy or remorse" (Sebern Fisher 2000) Hughes (1997, p7) elaborates: "In traditional child therapy, the child's relationship with the therapist is the critical foundation for change... However, with a child who has a profound lack of experiences of trust, there is a great deal of difficulty on his part in beginning to trust the therapist... The child perceives the therapist's acceptance and nondirectiveness as qualities that are easy to control and which result from his successful manipulations. The child's goal is often only to maintain control of the therapy session". Hence, a specialised therapy, termed Attachment Therapy, has evolved. Parent-child attachment is seen as its central goal. Parents are actively involved in all sessions, and a great deal of time is spent on parent education. Attachment therapists use a variety of strategies, e.g. interventions from EMDR, Theraplay ©, psychodrama, narrative therapy. Therapy is always directive. Treatment is holistic, aimed at facilitating secure parent-child attachment; treating the underlying effects of abuse, trauma or neglect; addressing the various social systems in the child's life; and involving a large component of parent education. Parents are seen as co-therapists in their child's life, and are taught to understand the causes and effects of attachment disorder, therapeutic parenting and survival skills. Many parents feel "burned out" and emotionally abused by their child's pathology, and so support and, sometimes, therapy is given to them in order to enable them to find the strength to parent their child in the most helpful way. We've come in contact, as professionals and adoptive parents, with a number of families whose adopted children are suffering as a result of poorly-understood attachment issues, and, more seriously, attachment disorder. Their families also suffer intensely as a result. The outlook for a lot of these children is pretty grim. We believe that parents and professionals alike need to learn how to facilitate attachment, how to recognise attachment disorder, and to view attachment as a fundamental and crucial issue for every adoptive family. Parenting a child with Reactive Attachment Disorder
Reactive Attachment Disorder of Infancy or Early Childhood
Specify type, based on predominant clinical presentation: Inhibited Type. Failure to interact predominates Disinhibited Type. Indiscriminate sociability predominates http://www.geocities.com/morrison94/child.htm#Attention Kent HoffmanDepartment of Pediatric Psychotherapy Marycliff Institute 807 W. Seventh Ave. Spokane, WA 99204 United States of America Phone: 61 - 1 - 509-455-1422 ext 54 E-mail: henthoffman1422@comcast.net Debbie is an adoptive mother who is also a mental health nurse and counsellor. She has a special interest in attachment issues and attachment disorder. Her email address is: dpj1@optushome.com.au |
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