Attachment is, essentially, the enduring emotional closeness which binds families, enabling children to be brought to independence and to parent in their turn. It is the template for the emotional rapport which is the stuff of all relationships, and thus of the functioning of society. At an individual level it is to do with the experience that “safety”—physical and emotional—is achievable through relationships.

While everyone needs attachment, for children it is the means to independence. The long duration of human childhood testifies to its importance and reflects the complexity of tasks involved. Attachment gives children the trust and safety necessary to explore, learn, and relate, and the physical wellbeing, motivation, tools, and opportunity to do so. Implicit in “safety” is the ability not only to recognise risk but also to adjust to it, both automatically and in a more considered way. Attachment is the foundation for doing so. Implicit in “trust” is the notion that relationships are mutually beneficial. Early attachment has lifelong implications for personal, social, and professional relationships, stress regulation, and physical and psychological health. Without it, “protection of children, prevention of illness and disease in children and safeguarding their optimal development”¹ is a vain hope.

Bowlby’s conceptual description of attachment² is supported by a wealth of observation and, increasingly, by neurobiological evidence. Ainsworth et al categorised toddlers’ varying responses to separation from and reunion with their parents.³ The observed patterns of relationships (“attachment styles”) are now recognised to originate in infancy and to track throughout the lifespan, albeit modified by later experience—influencing behaviour, health, career choice, and personal relationships (box 1). While “secure” attachment style may give the most comfortable personal path through life, societies benefit from attributes common among those with “insecure” attachment styles, the implied pathology having qualified justification. For example, those whose “insecurity” is manifest in anxiety to be needed or noticed can excel as “carers”, actors, or socialites, while those who seem emotionally self-sufficient, although tending to be socially inexpert often have particular talent with the inanimate or conceptual—computers or mathematics, for example. Attachment style forms a continuum on which pathology is imprecisely defined. It is a problem if it is a problem. It may colour, mould, or define children’s experiences in illness and health. Resilience varies for many reasons, both individual and social, and what is “good enough attachment” for one person may not be for another.

Much of the harm of abuse is that of disturbed attachment. Bruises heal quickly but the emotional relationships surrounding them can have implications for generations to come. The bruise may in fact, ironically, be the saving grace which allows professionals to respond since it is more readily defined. The powerlessness which many feel when witnessing emotional neglect unaccompanied by physical or sexual abuse can be helped by defining it in terms of the nature and implications of the inadequate attachment it represents. The difficulty is partly that this is rarely black and white—neglect and abuse can sit alongside aspects of important attachment. The nature of family attachments is thus a key consideration in weighing up risks and benefits of foster care, and in safe interpretation of parents’ and children’s responses to removal and contact. When attempting rehabilitation, recognition of the implications for family relationships of the child’s moves into and within foster care determines the preparation and support needed. Similarly, when adoption is required, children’s preconceptions of relationships are important considerations which profoundly colour the experience for all concerned.

Inadequate attachment is highly costly to individuals and to society. It frequently underlies drug and alcohol addiction, homelessness, criminality, and mental health problems⁵ and is a core strand in trans-generational parenting difficulty.⁶ Protection of attachment concerns all paediatricians, through recognising risks, actively promoting infant attachment, and identifying signs of attachment difficulty and its consequences.

Attachment colours all areas of paediatric practice. The question is not whether it is relevant, but how and to what extent. Insecurity of attachment may be relevant to symptom causation or perpetuation—excessive crying in infancy, sleep problems, conduct disorder, attention deficit hyperactivity disorder (ADHD), soiling and wetting, failure to thrive and obesity, accidents, small head circumference, and developmental delay among many. With every symptom children behave and parents respond in ways influenced by their respective attachment patterns For example, anxious attachment predisposes to use of symptoms, however trivial, for attention. Parents’ and children’s attachment styles may be relevant to mode of symptom presentation, the course of consultations, treatment compliance, clinic attendance, progress of recovery, and optimal management. The course of chronic illness, and resilience in the face of it, may both influence and be influenced by family attachments, particularly when illness straddles attachment related developmental stages. Care of adolescents requires particular awareness of the importance of attachment for safe separation, and of the complex dynamics around this into which professionals can readily unhelpfully be drawn. Adolescent attachment is characterised by paradox and ambiguity—the need, for example, for dependence to allow independence and for containment to allow empowerment. Recognition of this is necessary for protection of key relationships and for safe negotiation of consent.

Experienced paediatricians who routinely consider the “whole family” may reasonably wonder what greater awareness of attachment might add. It is really a matter of perspective. Seeing through “attachment tinted lenses” can make it easier to understand, analyse, and respond to many notoriously challenging aspects of practice. It contributes conceptually to defining and managing the psychosocial dimension of paediatric care. Recognising this as ubiquitously relevant enables the bigger picture of family and social relationships to be considered constructively, without judgement or implied criticism. It follows that this must be integral to paediatric practice and not territory only for Child and Adolescent Mental Health Service (CAMHS) professionals.

DEVELOPMENT OF ATTACHMENT

The key to attachment is attunement. Put simply, the baby’s cry elicits a calming parental response, reinforcing a learnt pattern for both.⁷ In fact this is a highly sophisticated duet, involving tone, pitch and rhythm of voice, posture, facial expression, movement, and touch.⁸ This moulds development of the experience dependent brain—particularly the occipitofrontal cortex—in a process requiring both the baby’s ability to elicit a response and the parent’s to respond.⁹

Stress regulation—a prerequisite for exploration, learning, and effective relationships—is a key aspect of this. Involuntary aspects, mediated by the hypothalamus-pituitary-adrenal (HPA) axis, are set in infancy—and probably antenatally—at a level adaptive to environment. “Higher” aspects, located in the right hemisphere,⁹ build on and regulate, but do not replace involuntary mechanisms. Hence, while neuronal plasticity, developing cognition, and experience modulate stress responses, they do so around a baseline reflecting initial relationships. This principle can be extrapolated to other aspects of development.

Attuned parental responses impart meaning to the “inner world” of body signals (for example, hunger, satiety, full bladder), thought (for example, recall, anticipation, problem solving), and emotions. The child learns that his emotions and behaviour influence those of others, who recognise his needs. Herein are the foundations for trust and empathy, understanding relationships and the subtleties of communication, non-verbal and verbal. Expectations (“internal working models”) are established for subsequent relationships, close and otherwise.¹⁰ Close relationships become distinguishable from others (table 1).

Increasing distancing from the mother is allowed in progressing from maintaining closeness initially through touch, to visually in the toddler years, then, increasingly, through language—including, specifically language for feelings. Trust allows security during physical separation and the emotional “separation” of discipline—the foundation for accepting authority and, through unconditional acceptance, for self-esteem. The “secure base” of attachment, remains, paradoxically, the cornerstone of growing independence throughout adolescence.

CHILDHOOD ORIGINS OF ATTACHMENT STYLES

Early attachment experiences, coloured by innate characteristics and experience shape approaches to all relationships. Consistently sensitive and responsive parenting teaches that closeness is valuable and that moderate distress elicits a response—the foundation of secure attachment. However, attunement presupposes “availability”, whether physical or emotional. For many parents this is not the case, whether through drug or alcohol abuse, mental health problems, or the practical demands of parenting several children. Many cannot attune since nobody attuned to them in childhood. Intermittent responsiveness (for example, through drug addiction) engenders anxiety, teaching that closeness is valuable but unreliable. Strategies are learnt to achieve it—ranging from constant smiling or excessive compliance to disruptive behaviour, smearing, wetting, or sexually provocative behaviour. Parents who are sometimes responsive but sometimes antagonistic (for example, because of temper control problems) teach that closeness is worth striving for, but often frightening, creating ambivalence—the child who, confusingly, seeks but is not calmed by closeness, uses closeness inconsistently or resists sustaining it. Consistent unresponsiveness (for example, through parental learning difficulties) teaches children not to seek closeness. Abuse by parents, or loss of important relationships, may likewise encourage avoidance of closeness, sometimes mimicking autism. When parents are a constant source of fear children may fail to learn strategies either for effective self-sufficiency or for using relationships, showing “disorganised” attachment behaviour.

As in any relationship, parent-child attachment is a two way process, dependent on what each contributes, opportunities for closeness, and the effects of, and on, other relationships. Apparent avoidance of closeness may reflect innate difficulty in responding, acquired intolerance of closeness (as with the irritability of drug withdrawal or neurological problems), lack of parental “availability”, or taught self-sufficiency. Anxious and ambivalent relationships may reflect innately anxious personality, cognitive difficulty, erratic parental availability, difficult subsequent relationships, or instilled anxiety.

The cause of parents’ difficulties does not predict children’s attachment patterns precisely. Drug addiction, for example, often allows intermittently attentive parenting, creating anxious attachment, though associated violence may produce ambivalence or avoidance of closeness. Abuse can cause avoidance of closeness, anxiety, or total disorganisation. Parental behaviour and resulting attachment patterns are changeable and distinctions blurred. Circumstances and “availability” change. One responsive parent may compensate for the other’s shortcomings and any close relationship may protect. Patterns are neither entirely mutually exclusive nor entirely fixed—though tendencies persist.

RISK FACTORS

Bearing in mind that attachment is a two way process, risk may lie in attributes of the child or parents, in opportunity for closeness, and in family and social relationships. Disability, traumatic delivery, post-natal depression, neonatal intensive care, circumstances of conception, altered family dynamics, and social attitudes can contribute.

However, attachment difficulty sufficient to lead to adoption almost invariably originates with the parents. Most lacked a parenting role model, were in care, or abused. Many have learning difficulties, mental illness, temper control problems, or drug or alcohol addiction—often several of these (Selwyn et al, 2003; unpublished). Routine enquiry in antenatal clinics about parents’ early attachment experiences would offer scope for education and focused intervention. Such information should be integral to child protection assessment.

CONSEQUENCES OF ATTACHMENT PROBLEMS

Disturbed attachment can affect all that should come of dependency, but particularly prominent aspects are, broadly, social communication, emotional awareness, and stress regulation. At school age these translate to interrelating problems with peer relationships, self-esteem, education, and discipline (box 2). Vicious circles and cascades of escalating difficulty follow, risking failure to sustain adult relationships, unemployment, homelessness, criminality, self-injurious behaviour, and parenting problems. Adolescence brings particular vulnerability.

Salivary cortisol marks an important thread throughout. The emerging picture suggests that some, in response to early traumatising relationships may switch off their stress responses—effectively withdrawing emotionally, becoming “fearless”. Others’ stress responses become exaggerated, carrying risk of anxiety, depression, and post-traumatic stress disorder.^11–13 The relevance of cortisol to attachment suggests research which might help to refine the non-accidental injury evidence base, in view of the relation of cortisol to ease of bruising, bone density, and rate of healing. Both suppressed and exaggerated patterns of stress responses have implications for behaviour regulation, compliance, and discipline.^14,15 Associated changes in bowel flora and immunological and cardiovascular function need further exploration.^16–19 The neurobiology of attachment illustrates one mechanism for the straddling of physical and psychological symptomatology, mediated by autonomic function and cortisol, with potential relevance to wider aspects of paediatric practice.

Depression frequently follows disturbed early attachment although its manifestations may be confusing—inviting failure and rejection, for example. A prominent need for order following early chaos can fuel obsessionality. With associated fear of closeness, literal language, limited empathy, and difficulty reading social cues this may mimic autism. Mistrust of authority and learnt self–protective strategies for maintaining control contribute to oppositional problems.

ADHD is complexly related to disturbed attachment, as both cause and effect. Familial ADHD is likely to be over-represented among those with attachment difficulty. Impulsive parents struggle to parent impulsive children—and ADHD may underlie the drug, alcohol, and temper problems which precipitate neglect. Antenatal risk factors for ADHD—drugs, alcohol, smoking, and maternal anxiety—are common among those with attachment difficulty. Hypervigilance in response to aggressive parenting and chaos precludes concentration. Hyperactivity may serve to avert closeness, or to attract attention. Hyperactivity and inattention, in turn, impair both physical and emotional closeness. Such behaviours escalate following moves, risking placement breakdown.²⁰ New parents struggle to cope without a safety net of mutual attachment. A trajectory of multiple moves may follow.

ATTACHMENT ISSUES IN DECISION MAKING IN CHILD PROTECTION AND SUBSTITUTE CARE

Attachment is central to evaluating risks and benefits of child protection decisions (table 2). Physical protection may be achievable only at the cost of significant emotional harm. Decisions about the nature, purpose and timing of interventions should focus on the priority of securing attachment and the natural history of attachment difficulties.

The key practical question is “when is it too late?” Neurobiological evidence explains the observed importance of initial attachment in protecting against subsequent inadequacy—adequate foundations may allow some room for manoeuvre.^9,21 The longer children are deprived of adequate attachment, the greater the risk of inability to achieve it.²² The likelihood of good recovery, even with optimal opportunity, progressively falls, though neuronal plasticity offers some resilience. Cortical atrophy becomes increasingly irreversible, with little demonstrable recovery a year later if children are removed from neglect after age 4 years.²³ Disordered attachment in infancy permanently affects HPA axis function.⁹

Secondary difficulties escalate with age, while the likelihood of identifying an adoptive placement diminishes. The outlook is bleak for those who by adolescence fail to achieve attachment sufficient for safe separation. The drive for independence makes integration into an adoptive home difficult in the unlikely event of finding one. While it is tempting to persevere when there is any chance of family care, the risks of passage of time mean that the probability, not the possibility of change needs to be considered. Age, and the timescale of interventions are key considerations. The practical need is to move forward regardless of cause, analysing what can be changed, how soon, and the cost of delay.

Decisions to accommodate must balance risk with the likelihood of success. This means recognising attachments to parents and others—teachers, siblings, and pets. Emergency placements are particularly hazardous since attachments cannot be assessed, risks identified, or children and families prepared. Difficulty managing the behaviour of distressed children risks placement breakdown, leading some to a trajectory of multiple moves and escalating damage. Balancing emotional harm against physical safety may entail accepting some risk. Hope of ultimate reunification determines the professional responsibility to minimise damage to key relationships through removal.

Attempted rehabilitation should be supported by awareness that both child and family are changed by separation. Preparation and support are as important as in moves to adoption. In both situations a broad focus on the child, parents, environment, family dynamics, and support networks gives the best chance of success.

The appropriateness of adoption, choice of family, and preparation and support needed for adoptive parents and children depend on the nature of birth family relationships. Children are to some extent attached even to the most abusive of parents, if only through familiarity. Loyalty to parents, sexual abuse in the context of “the favoured child”, perceived responsibility for family break-up, and experience of partially attentive parenting may all cause rejection of alternatives. It is rarely more difficult to engage parents, nor more important, than when children are removed from their care. Their support is often the key to allowing the child to move on. Acknowledgement of the origins of their own difficulties may enable them to feel less judged, tempering antagonism for some. Counselling independent of social services may enable some to support their child.

ASSESSING ATTACHMENT

In a busy clinic observation may raise concern about adequacy of attachment and its relevance to presenting problems (box 3). Frequently, though, the more relevant question is not “Is there an attachment problem?” but “What does the observed pattern of family attachments suggest about how the child and family may be helped most effectively?”.

The central question is “How does the child use adults?”. One considers whether he seeks closeness and attention appropriately (suggesting secure attachment), too little (suggesting avoidance), or too much (suggesting anxious attachment); whether he seeks but is not calmed by closeness or seeks it inconsistently (suggesting ambivalence), or whether his interpersonal behaviour appears chaotic and ineffective (suggesting disorganised attachment). Attachment style is frequently transmitted from parent to child, and parental interactions can yield helpful insight into children’s attachments. Detailed assessment requires analysis of information gathered from community based services (table 3). Description is more important than labelling, which needs a clear purpose.

Context affects interpretation. This is rarely more important than in evaluating options for permanency while children are temporarily “looked after”. Overlooking the bigger picture carries risk of misinterpreting children’s responses to accommodation or subsequent parental contact. Poor attachment of an accommodated child may not mean inability to attach. Each relationship is unique and ability to attach to one person does not necessarily predict ability to do so to another. Rate, strength, and quality of attachment vary within and between relationships. Initial avoidance of closeness is usually a healthier sign than the converse. A child’s attachment to his parents may make him resist alternatives. He may dislike the foster carer. The foster carer may herself have attachment difficulties.²⁴ Frozen unresponsiveness on moving to foster care may reflect fear of what is, not of what has gone before. Distress on seeing parents may reflect love, not fear. Relationships are dynamic, so snap-shot views, like photographs of moving objects, are not necessarily representative, and sometimes entirely deceptive. Over-hasty interpretation risks erroneous conclusions.

Unrealistic expectations of attachment frequently cause new adopters unanticipated difficulty. Idealisation founded on years of infertility causes fear and guilt when feelings are slow to develop. Parents usually attach at different rates, and to one sibling before another. Challenging behaviour of unsettled children adversely affects closeness. Behaviour once adaptive to inadequate parenting causes confusion and distress. Parenting without attachment is difficult, frightening, and isolating. One cannot know it will happen until it does so.

HELPING ATTACHMENT

This is a task for all—not only for CAMHS professionals. The importance of early attachment should be reflected in resource allocation, education, antenatal recognition of risk, and urgency of intervention. Key foundations need protection while parenting is assessed—through mother and baby foster placements and improved community resources.

Supporting attachment means recognising the bigger picture—support networks, family dynamics, opportunity for attachment and respite—remembering that attachment is a two way process. A broad based approach is needed, simultaneously addressing remediable elements while promoting resilience, particularly through self-esteem.²⁵ Within this, attachment develops, essentially, through “safety” and attunement—safety through routine, explanation and minimising failure, attunement through responding to the feelings behind behaviour rather than the behaviour itself⁴ (table 4). Encouraging understanding of feelings, non-verbal communication, and social cues can begin long before the need becomes apparent through peer relationship problems.

When adoption is deemed necessary, the choice of family must accommodate the implications of the child’s preconceptions of relationships. For example, a child insecure about achieving closeness may struggle to compete with one born to the family, focusing feelings onto this child, risking placement breakdown. Sibling relationships reflect parental attachment and need careful assessment. For example, insecure siblings placed together may thrive on each other’s failure, with a see-saw effect, risking rejection of one. A home allowing each adequate individual attention is the key.

Strategies adaptive to inadequate parenting, and the effects of fear of, or ambivalence to closeness feel confusing, personally directed and undermining—sometimes to the point of rejection. Understanding the feelings underlying such behaviour allows greater tolerance and empathy, helping the child to learn better ways of relating. Demanding as attention-hungry children may be, their parents generally feel needed, in contrast to the frustrations of parenting those who are emotionally aloof.

Historically, children with attachment problems have often fallen foul of CAMHS service structures and waiting lists in the “wait until he is settled” catch-22. Specialised provision is now increasing. Rapidity of response, separate parental support, flexibility, and continuity seem important. Without a safety net of mutual attachment, difficulty readily leads to crisis and risk of placement breakdown. Adoptive parents frequently feel inadequate and undermined when struggling with the legacy of early neglect—a position which professional involvement can inadvertently reinforce. The tasks required to achieve the priority of attachment need careful definition. “Attachment therapies” are time consuming, in short supply, and largely unevaluated. The extent of need is reflected in a demand for expensive private services.

Established attachment disorder is highly costly for children, families, and society. The focus needs to be on prevention and early intervention. Neurobiological advances now need to be accompanied by clinical research.

FURTHER READING

• Gerhardt S. Why love matters. Hove: Brunner-Routledge, 2004.