I should apologize now. This feels more like a term paper than a blog but in my effort to be as clear as possible, it just became more and more academic sounding. I will try to wrap up in simpler language by the end!
Last week in a support group, something was said that has just haunted me. A foster mom had to say goodbye to a 4-year-old who had come into her care when just a few days old. When she told her licensing worker about her reluctance to accept a new placement quickly, giving her time to grieve that loss, the licensing worker suggested she “not get so attached”. This remark betrays the licensing worker’s definition of the role of a foster parent: provide safety, shelter, food, and transportation to appointments. The foster mother’s grief betrays what she knows is needed for a child to grow up with the ability to give and receive love: a present, attentive, attuned, and responsive caregiver. The secret is in the word attuned. Once we take the step of paying close enough attention to be able to understand accurately what a child’s non-verbal communication means, it is nigh unto impossible to not get “so attached”. Once we assume the responsibility of meeting the needs of another, especially in the form of providing comfort, stimulation, and affection (by playing, feeding, cuddling, or rocking, etc.), we, too, become subject to the effects of the rush of oxytocin that goes with that experience. For most of us, that rush of oxytocin translates into a sense of connectedness and care, or attachment.
From https://www.endocrineweb.com, Oxytocin is released:
- In labor to stimulate the uterus to contract
- When a baby breastfeeds
- When touching someone you care about or when they touch you
- During hugging, kissing, intimacy, and sex
- When petting animals
- During exercise
- When surrounded by people you feel a connection with, such as friends and family
I would draw your attention to how many of these events can also be described as rhythmic and repetitious, e.g., breastfeeding, petting an animal, and exercise. The experience of these rhythms is regulating as well as attachment inducing.
Bruce Perry, MD, PhD describes attachment as:
- A special enduring form of an “emotional” relationship with a specific person
- Involving soothing, comfort and pleasure
- When the loss or threat of loss of the specific person evokes distress
- The child finds security and safety in the context of this relationship
I’ve written before about how you can prepare yourself for the sadness that comes with saying goodbye to a child you have come to care about. You can find that blog here on the AZAFAP website as Hope for the Best, Prepare for the Worst. I encourage you to read that if you need encouragement to “get so attached”. But let’s take a minute to explore an alternative course of action: protecting yourself from the pain of loss by NOT becoming attached to a child in your care. As Dr. Perry puts it, humans are “born for love”. To not receive love from a caregiver is the ultimate insult to a person hungry for connection and a young child who has experienced the chronic trauma of severely limited opportunities to form attachments is thought to be at risk for the development of something called Reactive Attachment Disorder.
According to the book psychiatrists use to classify patients for treatment and insurance purposes, the Diagnostic and Statistical Manual, IV-TR, (DSM-IV-TR), Reactive Attachment Disorder (RAD) presents as two types: the emotionally withdrawn/inhibited type and the indiscriminately social/disinhibited type. RAD is defined by the following criteria seen in a child before age 5:
- A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
- Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness, or fearfulness during interactions with caregivers
- Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
- No diagnosis of autism spectrum disorder (from https://www.mayoclinic.org/diseases-conditions/reactive-attachment-disorder/diagnosis-treatment/drc-20352945)
I and others take issue with this label because “…virtually all children form selected attachments to their caregivers in the latter part of the first year of life” and… “only a minority of young children who are abused and neglected develop attachment disorders … even among institutionalized children, most do not develop attachment disorders (from https://www.researchgate.net/profile/Charles-Zeanah/publication/228683818 Reactive Attachment Disorder a review_for_DSM-V/links/0deec51e86576d1e8c000000/Reactive-Attachment-Disorder-a-review-for-DSM-V.pdf). Keep in mind, however, that these early attachments with a disturbed caregiver may be marked by some seriously unusual attachment behaviors.
More useful than a diagnosis of RAD, there is research that describes three types of attachment types: Secure, insecure, and disorganized. The Secure type being protective of future social functioning, and the Disorganized type being a risk factor for future effective social functioning. The Disorganized type is described as resulting from abuse, trauma, or chaos in the home resulting in fear of their caregivers and having no “secure base” to turn to for consistent support, emotional safety, and comfort. There is even some evidence that these types do “not appear to reflect disordered attachment but rather a deviant tendency to violate culturally sanctioned social boundaries in interactions with others.” I would summarize this last sentence as: A matter of skill, not will. Children normalize early experiences and come to expect similar behavior from later caregivers. They are doing their best. It is up to us to make all the adjustments. It is useless to think they can adjust to our way of life. They are too quick to expect the worst of us to trust that we have their best interests at heart yet.
In case you aren’t convinced. Treatment strategies for Reactive Attachment Disorder include:
- Encouraging the child’s development by being nurturing, responsive and caring
- Providing consistent caregivers to encourage a stable attachment for the child
- Providing a positive, stimulating, and interactive environment for the child
- Addressing the child’s medical, safety and housing needs, as appropriate” from https://www.mayoclinic.org/diseases-conditions/reactive-attachment-disorder/diagnosis-treatment/drc-20352945
If you think an hour a week with a therapist or 6 months in a hospital or residential treatment setting is the ticket to a successful outcome, you might want to read those first two bullets again! Those settings offer 24 hr supervision but not the presence of a dedicated caregiver.
OK, now is where I get to sum things up.
In his Neurosequential Model in Caregiving©, Dr. Perry asserts that the way to help heal a child whose ability to trust caregivers has been compromised is to approach them in the same way the brain develops: from the bottom up. Making regulating activities, e.g., walking, rocking, bouncing, chopping, or brushing, etc., your first go-to intervention or preventive strategy, respects that the way to a child’s heart is through their brain stem. By taking good care of yourself, you can then trust yourself to have the emotional resources to deliver what your child needs when it is needed. You can’t regulate someone when you are not regulated. Being present, parallel (shoulder to shoulder to avoid a perception of intimidation), patient, and persistent, respects that the way to a child’s brain is through the gift of your loving relationship. Once these two steps become routine in your household, then and only then can you begin to collaborate with your child to explore creative solutions to their challenging behaviors. In other words: Regulate, Relate, Reason. If your child has a pretty messed up attachment style, this will look like a day spent alternating regulating activities with brief moments of shoulder-to-shoulder relational connectedness. First attempts at reasoned problem solving may be too dysregulating so you will have to back off! This sequence of steps is how you will chip away at their mistrust, lay down new neurological pathways and begin to mitigate those overreactions to even minimal stress that can derail your plans for the day. You may think I have overlooked discipline and how to mete out consequences but until a child is regulated, and a safe, even brief connection is made, their access to the parts of their brain that manage such intentional behavior remains out of reach.
Have confidence that your willingness to get so attached is the best gift you can bring to the child in your home. That and all the support you need to bring it consistently! Inquire about the next NMC class for a deeper dive into Dr. Perry’s approach to caring for a child with a history of chronic trauma.
- Check out the AZAFAP program events at Event Calendar.. Several new Circles of Supportive Families on now available. Reach out to find another parent who understands.
- Our Friday night Happy Hour and Tuesday afternoon Coffee Chat continue. Some find me and a single other participant; others find a conversation among 4 to 6 people. The topics range from the silly to what hobbies have us in their grip to what life has thrown in our path over the past few days or years. If you ever find yourself awake and wanting a bit of grown-up conversation, consider joining us (check your email for the unchanging link). Registration is also open for new, regional Circles of Supportive Families.
- Though pressures are easing, this pandemic continues for those of us who understand what is at stake. Others seem to struggle to grasp that. While we await vaccines for our kids, you are in my thoughts. Reach out if you need an ear: firstname.lastname@example.org.
- I encourage you to check out what Dr. Bruce Perry has to offer. Find his thoughts at https://www.pcaaz.org/wp-content/uploads/2019/07/B21-Insightful-Caregiving-Intimacy.pdf and at https://www.neurosequential.com/covid-19-resources.
Thanks for listening. Take care of yourself so you can take care of others.