adoptating children with attachment problems

Adopting Children withAttachment Problems

Daniel A. Hughes

This article describes children with significant attach-ment problems and summarizes the actions needed toincrease the probability that such children can be suc-cessfully adopted. Healthy and disordered attachmentpatterns are detailed, as well as the principles andstrategies that are important in parenting such childrenand the parenting characteristics that should be soughtin selecting families for children with attachment disor-der. Psychological treatment and other postadoptionservices necessary to support the adoption and thechild's ability to successfully form a secure attachmentwith the adoptive parents are also highlighted.

Daniel A. Hughes, Ph.D., is a psychologist in private practice. South China, Maine.

0009-4021/99/050541-20 $3.00 © 1999 Child Welfare League of America 541

542 CHILD WELFARE • Vol. LXXVIII, #5 • September/October

A successful adoption presupposes that the adopted childwill gradually, and yet in a timely manner, develop asecure attachment with his or her new family. Most chil-

dren are, in fact, able to form such bonds and the resulting at-tachment becomes the foundation for both their integration intothe family and for their ongoing psychological development.

Certain children, most often following months or years of se-vere neglect and abuse as well as multiple placements andcaregivers, develop gaps in their development that impede theirreadiness and ability to form attachments with their adoptivefamilies, no matter how loving and committed those families are.To facilitate the ability of such children to become a part of fami-lies, adoption professionals need to understand and develop spe-cialized programs for them.

The behaviors and needs of children with attachment prob-lems challenge the professionals responsible for them. After in-terviewing and observing a particular child, and describing himor her as being friendly, charming, affectionate, and engaging, anevaluator may often conclude that the child is able to form anattachment with adoptive parents. The author, however, usedsimilar adjectives in describing an 8-year-old girl whom he evalu-ated a number of years ago. This girl left him confused andtroubled when she asked if he could arrange for her to move fromfoster home to foster home every three months—her idea of anideal life.

Those evaluating children for adoption need to be aware ofthe observations and findings of professionals and researchersstudying children in institutionalized settings. In 1937, Levy de-scribed one such child as being "superficially affectionate andcharming" [Levy 1937]. Almost three decades later, Provence andLipton [1962] described many children in orphanages as "indis-criminately friendly." About the same time, Ainsworth [1961] de-scribed children with a history of maternal deprivation as overlyfriendly and "socially promiscuous." A child who initially is

Daniel A. Hughes 543

friendly and engaging can easily lead prospective adoptive par-ents into assuming that he or she wants—and is able to accept—a reciprocal and positive parent-child bond. Adoption profession-als must understand and communicate to prospective parents thatsuch friendliness may indicate the child has difficulty establish-ing selective attachments.

Children with significant attachment problems manifest fairlytypical behavioral patterns, which, in turn, tend to elicit fairlycommon responses from their parents. Such children may havelittle or no understanding about what constitutes a parent-childbond or the interest a parent has in acting upon the child's bestinterests. They don't understand that their parents' enjoyment ofand commitment to them is far deeper than their own particularwords or actions. Such children are often friendly with anyonesince they have found such friendliness to induce most adults tobe "nice." By smiling and being charming, they control the situa-tion, and, to a large part, the behaviors of the adults. The childdetermines, without thinking, what is best for him or her andbelieves that the task is to get the adult to do as he or she wants.

For children with significant attachment problems, the adult-child relationship itself is of little interest. It does not occur tochildren who lack an understanding of the parent-child relation-ship that adults would try to understand what was best for themand then meet their needs. As a result, these children assume thatthe adult must be manipulated or intimidated. Once the adulthas given the child what he or she wants, there is little desire fora relationship with the adult until the next wish comes along. Ifan adult grants many wishes and then says "no," the child willhave little use for that person and will try to find another adultwho will provide what is desired. If no other adult is present, thechild will turn back to the first adult and, aware that charm didnot work, will try to wear the adult down through intimidation,angry outbursts, threats, and defiant behaviors. If that fails, thechild will punish the adult for being "mean," usually by stealing


or breaking things or by doing things meant to make the adultangry and upset. The child essentially is saying, "You made meunhappy, so I'll make you unhappy too."

In the typical case, parents of such children begin the adop-tive placement by saying "yes" many times to try to build trustand reassure their children that they truly want to meet theirneeds. They overlook many situations in which a "no" might beindicated, hoping that, once the child's wishes have been metoften enough, the child will accept the rules and expectations thatare a part of living in their home. These children, however, willnot learn to accept the rules because they are focused on takingcare of their own wishes and have little empathy or concern fortheir parents or the interests of the rest of the family. When chil-dren with attachment problems do not begin to show any recip-rocal interest in the family, parents begin to blame themselvesand question their decisions and parenting capacities. After a time,they blame their children and come to believe that they are wantedby their children only for what they will provide at a particularmoment. They despair that their children will ever want a posi-tive, reciprocal, parent-child bond, a despair grounded on the re-alities of attachment problems.

Children with serious attachment problems are unaware ofwhat is missing in their relationships with their parents. Even ifthey were aware of this missing aspect of the relationship, how-ever, they would not choose to work for such a relationship. En-tering into a reciprocal parent-child relationship would requirethem to give up the control and self-reliance that have enabledthem to survive years of neglect and emotional isolation.

This article delineates an approach that adoption profession-als and programs can use to lessen the likelihood that the abovescenario will occur. Professionals must understand healthy de-velopmental attachment and the effects on children when it failsto occur. Prospective adoptive parents also must understand aparticular child's attachment problems and, in conjunction with


adoption professionals, decide whether they have the ability andmotivation to adopt such a child. Parents who make the decisionto adopt must receive training in parenting the child so they canmaintain the emotional stability of their home while slowly fa-cilitating the child's ability to form an attachment with them. Theyand their child will need specialized treatment that facilitates thisprocess and a range of postadoption supportive services.

The disruption of an adoption does not necessarily mean thatthe child had significant attachment problems. Adoptions dis-rupt for a variety of reasons. The adoptive parents may not haveengaged in good parenting because of factors that have nothingto do with the child: there may have been a poor match betweenthe child and family; or the child may have manifested disrup-tive testing behaviors during the initial months of the placementthat may reflect anxiety about forming an attachment rather thanproblems forming an attachment. The nature of a child's attach-ment-related behaviors should always be identified by a quali-fied professional to determine whether the child's functioningrepresents significant attachment difficulties or other factors.

The Development of Attachment

Normal Developmental Attachment

During the first year of life, infants are social beings whose sen-sory systems focus on interacting with their primary caregivers.The child's mother easily senses how much attention her infantneeds and joyfully and repeatedly offers it to him.* She touchesand holds him, moves and rocks, sings, smiles, and uses exag-gerated facial expressions and "babytalk" to communicate heremotions. During such interactions, which some researchers havecalled "attunement" (referring to the sharing of affect between

* The feminine and masculine genders are used here for ease of reading and are notmeant to imply that fathers do not form attachments with their infants, or that malechildren develop attachment disorders at a higher rate than female.


mother and infant), the infant's brain is stimulated, positive emo-tions of interest and joy develop, and the child begins to feel spe-cial [Stern 1985; Schore.1994]. During the first year, the child in-creasingly prefers his mother and becomes selective in his choiceof adults with whom to relate. He also discovers that interactionswith certain adults are the source of much meaning and enjoy-ment in life.

In contrast to the first year, when the mother teaches her in-fant that he is special, during the second year, the mother teachesher toddler that other members of the family are special as well.She begins to actively socialize her child by saying "no," chan-neling his behaviors, setting limits, and not responding to all ofhis wishes. When she frustrates her child's wishes, he feels shame,which is the mother's primary socialization intervention [Schore1994]. During these interactions, there is no attunement and thetoddler avoids eye contact, tries to hide, and becomes motionlessand speechless. This experience of shame causes emotional dis-tress, which the mother intuitively recognizes. She reattunes withher child with a smile, touch, or supportive word, and reassureshim that he is special but also that he must be aware of the rightsand feelings of others. Within moments, the toddler feels specialagain as his mother has comforted him in his distress, which shehad caused by saying "no."

Begirming in the second year and well into the third year, theyoung child, within the safety of this secure attachment, learns tointegrate both attunement and shame as well as his own wishesand the demands of socialization. He learns how to remain closeto his mother, the source of both pleasure and distress. As he learnsto accept fully the "good" and "bad" mother as the same person,he learns to integrate and accept the "good" and "bad" parts ofhimself. This integration is crucial if he is to internalize all fea-tures of his mother and incorporate his attachment to her into hisdeveloping sense of self [Mahler et al. 1975]. The child developsthe ability to consistently feel empathy, tolerate frustrations, regu-late his emotions, control his behaviors, and recognize the differ-


ence between right and wrong. He becomes aware of and able toarticulate his thoughts and feelings and begins to soothe himself.As he "downloads" his parents' love into his developing self, hetrusts that they will do what is best for him and will keep himsafe. A secure attachment and a well-integrated self are two sidesof the same reality, enabling the child to feel that he is special.Securely attached, he can proceed with the developmental tasksthat lie ahead [Greenspan & Lieberman 1988].

Over the past 50 years, the importance of attachment in theparent-child relationship has been studied extensively [Karen1994]. Attachment theory, which originated in the work of JohnBowlby and Mary Ainsworth, has come to refer to the role ofattachment in both healthy psychological development and indevelopmental psychopathology [Bowlby 1988; Ainsworth 1978].Attachment is thought to have a central role in future relation-ships and psychopathology because the original parent-childbond is believed to provide the working model for all subsequentmeaningful relationships [Cicchetti et al. 1995]. The readiness andability to engage in reciprocal, enjoyable relationships through-out life is based on the countless attunement experiences thatoccur during the first few years of life. The ability to experienceand resolve conflict is based on early experiences of shame thatare followed by reassurance and reattunement with primary at-tachment figures. The ability to integrate the need for intimacywith the need for autonomy depends upon how successfully theindividual internalizes primary attachments into early identitydevelopment. Given its central role in early psychological devel-opment, it is easy to see why a secure attachment is thought to becentral in a child's developing ability to regulate emotions, con-trol behavior, and establish an integrated sense of self [Schore1994].

The Effects of Abuse and Neglect on Attachment

Child abuse and neglect have been shown to greatly impede thedevelopment of secure attachment [Crittenden & Ainsworth


1989]. Increasingly, the central factor in the intergenerational trans-mission of childhood maltreatment is thought to be disorders ofattachment [Cicchetti 1989].

Difficulties in establishing and maintaining a secure attach-ment with one's primary caregivers are likely to exist on a con-tinuum from mild to severe. Many children who have beenabused, neglected, and/or subjected to multiple caregivers havesymptoms that may not meet the full diagnostic criteria for sig-nificant attachment disorders, yet they may manifest various char-acteristics that reflect a disorganized, anxious-ambivalent, or anx-ious-avoidant attachment with their primary caregivers[Crittenden & Ainsworth 1989]. Other children manifest severedifficulties with related attachment.

The developmental sequence that characterizes a secure at-tachment contrasts significantly with that of a child who experi-ences chronic neglect, abuse, and placement with multiplecaregivers. Often, the maltreated child does not discover that heis special; does not learn the joy and interest that is elicited fromexperiences of shared affect with his mother; and does not feelaffirmed, identified, or important. Instead, he increasingly feelsisolation and sadness and may eventually feel despair and thatthere is little to live for. Because his basic needs for food, warmth,and physical comfort are most likely not consistently met, hisinterests increasingly turn to meeting these fundamentals. Helacks confidence in his own developing abilities and in his par-ents, whom he sees as not concerned with his best interests.

Eventually, the child discovers options that may help get hisneeds met—screaming at, charming, or manipulating others tosomehow "make" them do things for him, or finding ways to getwhat he needs on his own. He becomes increasingly self-reliant,rejecting the urge to be supported and comforted, and choosesinstead to try to control his environment.

The maltreated child is also shamed constantly, first with non-verbal messages that his parents have little interest in him, and


then by rejection when he begins to be mobile and to elicit hisparents' rage [Schore 1994]. He quickly learns to dissociate him-self from the intense shame and his profound feelings of worth-lessness and to deny the shame. He withdraws into fantasy and/or obsessive plotting about controlling the future, and places thesource of his pain outside of himself, assuming a "tough guy"attitude and/or that of an "innocent victim." The child becomesincreasingly successful at concealing his pain and his vulnerabil-ity, first from others and then from himself.

Pervasive shame becomes a major part of the child's exist-ence as his shame "experiences" are seldom followed by reassur-ance and comfort [Schore 1994]. Gradually, he begins to resistothers' efforts to comfort him and learns to deny feelings of want-ing to be nurtured and comforted. He experiences what little com-fort he can through controlling others, causing them distress,learning to manipulate and intimidate, and acquiring objects inwhich he has little interest.

When a child with this background is invited into an adop-tive family and offered the opportunity to have a positive recip-rocal relationship with someone who wants to meet his needs, heis likely to be confused and frightened. He begins to reexperi-ence feelings from his infancy, i.e., the wish for attunement thatnever was fulfilled, as well as pervasive shame, but he quicklyminimizes and denies these feelings. The child rejects the affec-tion and playful interactions that are offered because he feels vul-nerable and has no confidence they will last. He also rejects rou-tine socialization and discipline because he associates disciplinewith feelings of intense shame. Because of his past experiences,he is not interested in a reciprocal relationship or in mutual en-joyment and shared responsibilities. A child without a history ofsecure attachments is likely to develop a variety of symptomsthat reflect an isolated and painful developmental path: little em-pathy for others, limited awareness of the consequences of hisbehavior, little guilt and remorse, difficulty expressing thoughts


and feelings, and poor discrimination among relationships. Theregulation of bodily functions, emotions, and behavior may bepoor, with much variability among situations and experiences.At the same time, the child often has an excessive need to controlevery situation.

Reactive Attachment Disorder

When a child manifests most of the above symptoms to a signifi-cant degree, he may meet the diagnostic criteria for Reactive At-tachment Disorder (RAD). This disorder is defined as "markedlydisturbed and developmentally inappropriate social relatednessin most contexts, begirming before five years of age." RAD maybe characterized as either "inhibited" or "uninhibited." In theinhibited type, social interactions are "excessively inhibited,hypervigilant, or highly ambivalent and contradictory responses;"in the uninhibited type, the child manifests "indiscriminate so-ciability" without "appropriate selective attachments" [Ameri-can Psychiatric Association 1994]. As yet, there is no clear evi-dence that one type of attachment disorder is more severe thanthe other. It is also not clear whether most children with RADmanifest both types to some degree. At present, differentiatingbetween the two types of RAD does not have implications fortreatment or prognostic considerations.

Many children who have been abused and neglected mani-fest attachment problems to some degree, although they do notmeet the criteria for Reactive Attachment Disorder [Cicchetti1989]. An assessment of the severity of a child's attachment prob-lems should include a description of the child's specific symp-toms as well as answers to the following questions:1. How severe, chronic, and pervasive were the child's experi-

ences of neglect and abuse?2. How many caregivers did the child have? (Disrupted rela-

tionships with foster parents are each likely to be experiencedas rejection and abandonment. With each subsequent disrup-


tion, a child's readiness to form an attachment with the nextcaregiver is likely to be less.)

3. Were there any positive, continuing relationships during thefirst two years of the child's life?

4. Has the child begun to show any significant improvementsin his current family foster home?

5. Is there any selectivity in the child's attachments?6. Has the child ever shown grief over loss?7. Does the child accept help and comforting?8. Can the child enjoy, without disrupting them, close and play-

ful interactions that are similar to the attunement interactionsmothers have with their infants?

9. Does the child ever directly show shame over his behaviors?10. Does the child ever show sadness over the consequences of

his behaviors, rather than being enraged over their perceivedunfairness?

11. Can the child experience and give expression to sadness andto fears?

The Right Match

If a child has not shown signs of developing a secure attachmentwith a caregiver, it cannot be assumed that he will begin to do sowhen given the permanency of adoption, but neither can it beassumed that he will not do so. Professionals working with thechild should neither falsely promise positive results to prospec-tive parents nor conclude that the child is hopeless. Instead, theyshould strive to understand the child's attachment problems andto help the adoptive parents choose a child with whom they arewell matched.

The decision to adopt a child with significant attachment prob-lems is one that should be made only with full knowledge aboutthe child and after much deliberation. The adoptive parentsshould receive information on all aspects of the child's historyand symptom patterns; have opportunities to speak to the child's


foster parents about the nature of their relationships with himand whether these relationships have changed over time; behelped to assess how the child's symptoms and needs may relateto their own personalities and desires; and be given a realisticappraisal of the challenges that they will face and the skills theywill need to parent the child. Professionals should help the par-ents to understand that key skills include the ability to regulatetheir own emotions, deal with their child's rejection of them with-out taking it personally, and relate to their child with affectionand empathy w^hile remaining firm and persistent in socializingthe child. Parents also must have the ability to remain committedto their child even if he fails to make significant progress in hisability to develop a secure attachment with them. Finally, theadoptive parents should be provided with appropriate training,support, and treatment services to help them maximize theirchild's ability to securely attach with them.

Parenting Principles and Skills

When parents are able to help their child develop a secure at-tachment for the first time in that child's life, they are facilitatingthe "psychological birth" of their child. To reach that goal, how-ever, parents must recognize and overcome numerous conflictsand challenges.

Parenting children with significant attachment disorders re-quires the ability to engage the child in a manner that facilitatesthe same type of shared affective experiences other parents havewith their infants. A parental attitude that communicates empa-thy, acceptance, affection, curiosity, and playfulness increases thechild's ability to respond to the parent in the same marmer aswould an infant who was securely attached. This parental atti-tude, which is communicated when the parent places limits onthe child, allows the child to tolerate the shame that disciplineelicits and lessens the likelihood that the child will react with rage.


Because this attitude is not easy to maintain in the face of con-tinuing oppositional behaviors and angry outbursts, parents mustbe able to regulate their own emotions and not allow their childto control them. They must be able to express anger in responseto specific behaviors in a quick, direct manner, and then followthat expression with reassurances and comfort. Parents shouldnot take personally their child's rejection of their discipline andaffection.

Often, it is necessary to begin an adoptive placement by keep-ing the child in close physical proximity to his new parents sothey can make many of his choices for him and provide him w itha sense of safety. The child can begin to rely on his parents todecide which behaviors represent the best choice for him in thenew setting. This results in fewer consequences for misbehaviorbecause there are fewer misbehaviors, and the child is not re-peatedly engaged in experiences of failure and shame. This levelof physical presence may need to be present for weeks, or evenmonths before the child will begin to internalize the choices,wishes, and values of his parents. Most children with attachmentproblems, however, do adapt to this level of parental presence.

As the parents begins to give the child choices and unsuper-vised time, he is likely to initially make poor choices and respondto limits with oppositional behaviors and/or angry outbursts.Through the use of natural and logical consequences, parents canaccept the child's choices and provide him with empathy for theconsequences, striving to be "sad for" his distress over the conse-quence rather than being "mad at" him for his behavior. If, how-ever, the child repeatedly engages in the same misbehavior, con-sequences may need to be more comprehensive and of longerduration than is customary in raising children without attach-ment problems. Increased limits on the child as a natural andlogical consequence may be needed to prompt the child to ab-stain from the significant misbehaviors. When given with empa-thy and acceptance, natural and logical consequences are not pu-


nitive or rejecting and do not put a child at risk of reexperiencingthe abuse and rejection that characterized his original insecureattachments.

A child who repeatedly misbehaves is unlikely to respond topositive reinforcement, increased activities with his parents, orthe receipt of concrete objects. The best response to constant mis-behavior is to give the child the opportunity to be physically closeto his parents once again, as his behavior signals that he is notready for independence and freedom of choice. This requiredcloseness should be explained with empathy and acceptance, andwith assurances that eventually the child will have the opportu-nity for greater separateness.

Psychological Treatment of Children with SignificantAttachment Problems

Strategies based on traditional treatment principles are not likelyto be effective with children who have significant attachmentproblems because of the nature and severity of their psychologi-cal problems and deficiencies [Hughes 1997; James 1994; Levy &Orlans 1998]. Traditional therapy presupposes that the child hasthe readiness and ability to form a therapeutic relationship thatcan be utilized to resolve past traumas and form a more stableand positive sense of self [Greenspan 1989; Hughes 1997]. Chil-dren with significant attachment problems are not likely to enterinto a relationship with a therapist that would facilitate suchprogress, as they are likely to attempt to manipulate or intimi-date others, and a trusting relationship is not likely to develop.Thus, allowing the child to set the pace and direction, as is cus-tomary in traditional therapy, will lead to continuing avoidance.The pervasive sense of shame that characterizes these children'spsychological status will generate intense resistance to routinetherapeutic efforts; such children are likely to dissociate fromnegative affective experiences as a result. Additionally, because


traditional therapy sessions do not routinely involve parents, theyfail to incorporate a crucial factor in facilitating a parent-childattachment.

Therapy for children with significant attachment problemsshould be structured to replicate the attachment sequences thatcharacterize normal developmental attachment. The sequence ofattunement, socialization/shame, and reattunement must be thecentral therapeutic experience. With a primary emphasis on par-ent and therapist attunement with the child's ongoing affectivestates, the therapist should work to elicit and share positive af-fect with the child and provide the child with an opportunity toexperience surprise and delight in response to the adults' activeengagement with him. The child should be helped to feel safeand tolerate the affective intensity that is generated.

Once the child achieves some level of comfort and relaxation,the therapist should actively engage the child and help him ex-plore the sense of shame he has associated with both earlier ex-periences of neglect and abuse and current experiences of disci-pline and frustration in his adoptive family. Often, childrenstrongly resist becoming engaged with the therapist and theirparents and exploring their feelings of shame, fear, rage, and de-spair [Hughes 1997; Levy & Orlans 1998]. The therapist must workwith this resistance, empathizing the difficulty of the work, andshould approach the resistance with acceptance, playfulness, andcuriosity. The therapist may be the person who initially voicesthe realities of the child's early experiences of neglect and abuse,and should do so with empathy and understanding for the in-tense affect this information generates within the child. If the childis to become ready to develop a secure attachment, the therapistand the child's parents must support and comfort him as he gradu-ally faces these issues.

Frequently, parents and/or the therapist will touch and holdthe child as he becomes engaged in the stressful and intenselyemotional work. Physical contact may serve the same purpose as


the mother who spends so much time holding her infant. Whenan adult (the therapist or the parent) holds the child, the adult isattuned to the child's affective states and creates a "holding envi-ronment" that provides the child with the security he needs[Hughes 1997,1998; Levy & Orlans 1998].

"Holding therapy," a form of attachment therapy, has gener-ated some controversy. In early forms of this therapy, the thera-pist provoked the child into a rage, then held the child againsthis will [Hughes 1998]. Many questioned whether the child wasbeing retraumatized through this form of "holding" and whethera "trauma bond" was being formed [James 1994]. Today, mosttherapists who hold the child or have the parent hold the childwill first explain the intervention to the child and elicit the child'sconsent [Hughes 1997, 1998; Keck 1995; Levy & Orlans 1998]."Holding" then takes place in an environment of support andnurturing that facilitates the child's ability and readiness to be-come engaged in difficult therapeutic work.

The parents' presence in therapy is crucial. By being present,they can provide their child with emotional support, attunementexperiences, and safety during the stresses of treatment; help thechild to differentiate them from the abusive and neglectful par-ents in his past; and provide the child with the opportunity tolearn that he does not have to conceal his past from his parents.The parents can model how to express thoughts and feelings, andreassure their child about his worth in spite of his past experi-ences and current behaviors. Parental participation in therapyenables the therapist to understand how the child is functioningat home, and provides an opportunity to "check out" the child'sperceptions and to reinforce the parents' authority to the child.

Significant attachment problems tend to be quite resistant totherapeutic change [Hughes 1997; James 1994; Leyy & Orlans1998]. As a result, a long period of time is often needed for at-tachment therapy to facilitate an attachment that will have a majorinfluence on the child's functioning. When a child's attachment


problems are mild, the child may respond to the specific inter-ventions of attachment therapy in less than six to nine months.More often, 18 to 24 months are required before significantprogress is achieved. Even then, some children, either because ofthe severity of their early abuse and neglect or because of neuro-logical or constitutional factors, do not achieve the gains neces-sary for them to develop a secure attachment.

Other Postadoption Services

Children who resist forming attachments with their parentspresent their adoptive families with intense, ongoing challenges.For new parents to facilitate attachments with their children, theyneed considerable support within the adoption community—sup-port that is tailored to meet the unique needs of the poorly at-tached child and his family.

Support groups for adoptive parents of children with attach-ment problems can be of considerable benefit [Hughes 1998; Keck1995; Levy & Orlans 1998]. Often, other parents have the greatestunderstanding of the difficulties and stresses associated with rais-ing children with attachment problems, and are best able to offersupport and guidance on parenting interventions that proved tobe effective with their own children. Other parents readily un-derstand that the problems of children with attachment disor-ders are intense, real, and longstanding.

Respite services should also be provided for adoptive par-ents who are trying to meet their child's intense needs. Respitecare provides parents with time to relax and focus on their owninterests and on other relationships. The respite care providershould understand the nature and severity of the child's attach-ment problems, should be aware of the adoptive parents' rulesand expectations, and should be willing to follow those guide-lines. The respite care provider must also be able to anticipatethat the child may portray his parents as mean and unfair through


lies and half-truths. The respite care provider must understandthe important of making clear to the child his or her support ofand confidence in the child's parents.

Finally, in-home supportive services, provided by mentalhealth or family support professionals or paraprofessionals for afew hours each week, should be available to give parents a re-spite and enable them to continue providing an intense level ofparenting during the remainder of the week. For such services tobe helpful, however, in-home workers need to function as paren-tal assistants who reinforce parents' judgments, rules, and au-thority to the child. They must understand the nature of attach-ment problems and the interventions that are appropriate. Manyin-home workers are trained to employ traditional behavioralmanagement techniques. Such techniques, however, are likely tobe ineffective with children w ho have attachment problems.

If children with attachment problenrs and their adoptive par-ents are not provided with appropriate services, the risk of adop-tion disruption increases, as does the possibility that the childrenwill never achieve the security and support of a permanent adop-tive family [Keck 1995; Levy & Orlans 1998]. Children with at-tachment problems are at high risk for frequent moves amongfoster homes and other care settings. Under such conditions, theattachment problems the children have when they enter out-of-home care are likely to intensify and become more pervasive.Children who do not achieve secure attachments with significantcaregivers in childhood are likely to manifest various forms ofpsychopathology during adolescence and adulthood, and arelikely to have serious problems developing and maintaining at-tachments with their spouses and children.

Conclusion

A high level of skill and commitment is required when an adop-tion agency places a child who manifests significant attachment


problems. Adoptive placements should be carried out in a thor-ough, professional manner document the nature and severity ofthe child's attachment problems. Adoption professionals shouldmake the prospective adoptive parents fully aware of the child'sproblems, the services that the child requires, and the servicesthat may be needed in the future, as well as the parenting quali-ties that must be brought to bear to facilitate the child's readinessand ability to form an attachment. Finally, appropriate treatmentand supportive services must be available to the family.

Neglect and abuse may cause psychological problems thatgo far beyond traumatic stress. Chronic neglect, which has beencalled the "trauma of absence," can cause significant gaps in thedevelopment of the self. These gaps become evident when a childhas great difficulty in understanding the joy and satisfaction thatcomes from a secure attachment with his parents. A child withattachment problems needs the opportunity to learn how to be-come attached to good parents who will define for him parentallove and commitment, and show him his own worth and poten-tial. Such parenting is difficult and should be undertaken onlywith full knowledge of and willingness to confront the challengesinvolved. •

References

Ainsworth, M. D. S. (1961). Maternal deprivation reassessed. Geneva, Switzerland: WorldHealth Organization.

Ainsworth, M. D. S. (1978). Patterns of attachment: A psychological study ofthe strange situ-ation. Hillsdale, NJ: Erlbaum.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disor-ders (4th ed.). Washington, DC: Author.

Cicchetti, D. (1989). How research on child maltreatment has informed the study of childdevelopment: Perspectives from developmental psychopathology. In D. Cicchetti & V.Carlson (Eds.), Child maltreatment (pp. 377-431). New York: Cambridge University.


Cicchetti, D., Toth, S., & Lynch, M. (1995). Bowlby's dream comes full circle: The appli-cation of attachment theory to risk and psychopathology. Advances in Clinical ChildPsychology,17,1-75.

Crittenden, P., & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory.In D. Cicchetti & V. Carlson (Eds.), Child maltreatment (pp. 432-463). New York: Cam-bridge University.

Greenspan, S. I. (1989). The development of ego. Madison, CT: International UniversitiesPress.

Greenspan, S. I., & Lieberman, A. F. (1988). A clinical approach to attachment. In J. Belsky& J. T. Nezworski (Eds.), Clinical implications of attachment (pp. 387-424). Hillsdale,NJ: Lawrence Erlbaum.

Hughes, D. (1997). Facilitating developmental attachment. Northvale, NJ: Jason Aronson.

Hughes, D. (1998). Building the bonds of attachment. Northvale, NJ: Jason Aronson.

James, B. (1994). Handbook for treatment of attachment-trauma problems in children. NewYork: Lexington Books.

Karen, R. (1994). Becoming attached. New York: Warner Books.

Keck, G., & Kupecky, R. M. (1995). Adopting the hurt child. Colorado Spring, CO: PinonPress.

Levy, D. (1937). Primary affect hunger. American Journal of Psychiatry, 94, 643-652.

Levy, T. M., & Orlans, M. (1998). Attachment, trauma, and healing. Washington, DC: CWLAPress.

Mahler, M., Pine, R, & Bergman, A. (1975). The psychological birth of the human infant.New York: Basic Books.

Provence, S., & Lipton, R. (1962). Infants in institutions. New York: Intemational Univer-sity Press.

Schore, A. N. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: LawrenceErlbaum.

Stem, D. (1985). The interpersonal world ofthe infant. New York: Basic Books.

adoptating children with attachment problems

Documents

described children

certain children

particular child

adopted child

parentchild relationship

secure attachment

attachment problemsdaniel

resulting attachment