ATTACHMENT
ISSUES
IN POST-INSTITUTIONALIZED INFANTS by Jessica
Parenting
a baby from an orphanage is not identical to raising an a biological infant
from birth. Some of a newly-adopted baby's behaviors may not be developmentally
normal, but the expression of grief, or symptoms of attachment problems.
The parenting techniques recommended by childrearing manuals, pediatricians,
or other parents may not be appropriate in these situations. If a baby
is passive and withdrawn, sleeps more than usual, cries and rages constantly,
wakes and cries often in the night, or becomes totally clingy, these can
initially be symptoms of grief. It is normal for babies to grieve for
the loss of familiar caregivers and environment. But persisting, or newly
emerging abnormal behaviors may be signs of insecure attachment.
WHY POST-INSTITUTIONALIZED CHILDREN ARE AT RISK OF ATTACHMENT PROBLEMS
Post-institutionalized infants experience several traumas: abandonment
by their birthparents, life in an orphanage, and adoption and removal
to a totally new environment. These experiences place these babies at
risk for Reactive Attachment Disorder. Individuals with this personality
disorder are unable to give and receive love. They cannot develop the
ability to form successful relationships, or accept responsibility for
their actions, and lack cause-and-effect thinking, empathy towards others,
and a conscience. They are typically angry, oppositional, defiant and
do not trust others. Insecure attachment can be ambivalent, avoidant or
disoriented-disorganized. Most internationally adopted babies do not have
severe Reactive Attachment Disorder, and form largely secure attachments
to their new families. But some attachment therapists conclude that all
post-institutionalized children can be expected to have some level of
attachment difficulties, given their traumatic early experiences. For
normal emotional development, babies needs a primary caregiver who responds
quickly, consistently and lovingly to their demands, so they learn that
their needs for food, clean diapers, pain relief, etc will be met, and
develop trust and attachment. Babies need to feel that their world is
safe and secure. The baby has an internal cycle of need-rage-relief-trust,
which needs to be completed hundreds and hundreds of times. Babies also
need a one-on-one interaction with a caring individual who will cuddle,
play interactive games, sing and talk to them. They need to be touched,
to receive and give smiles, and to get lots of eye contact from a loving
caregiver. This consistent, constant, warm and often playful interaction
with the caregiver is how a baby learns to receive and to give love. Orphanages
cannot provide this level of individual one-on-one care. In many institutions,
a succession of nurses provide only minimal physical care, changing diapers
infrequently, occasionally washing the babies, and propping bottles so
the babies feed themselves. Babies are left for long hours alone in their
cribs. With a ratio of one caregiver to perhaps ten or twenty babies she
cannot attend to each infant when the baby cries from hunger, pain, discomfort
or for attention. When she does not respond to crying, the, babies never
learn to trust that their demands will be met. Nor do they get the cuddling,
baby games, baby talk, and other playful interaction they need.. As a
result, babies may give up trying to get their needs met, and feel only
the emotions of rage, helplessness, fear and shame, never developing the
trust and the sense that the world is safe and secure essential for successful
attachment. Until recently, many adoptive parents assumed that post-institutionalized
children under age one would quickly and completely overcome this early
emotional deprivation once they were in a loving family, and that only
children adopted as toddlers and older were at risk of developing Reactive
Attachment Disorder. Indeed, this may be a factor in choosing only to
adopt an infant. But now parents are recognizing symptoms in their babies,
and children who seemed to have attached well begin to display symptoms
of attachment problems as toddlers, preschoolers, or in elementary school.
As they grow older, new inappropriate behaviors, typically more extreme
or excessive than developmentally normal, may indicate emerging unresolved
attachment issues.
WHAT ARE THE SIGNS OF ATTACHMENT PROBLEMS IN BABIES? Initially, some of
these behaviors may be caused by grief, in which case they will disappear
quite rapidly in most cases. Other behaviors may seem within the range
of developmentally normal developments, but parents sense that they are
excessive and inappropriate .Attachment is a gradual process, which takes
many weeks and months, and typically concerned parents wait a few weeks
to see if the symptoms disappear, as they often do. If your baby has obvious
and severe symptoms, however, you should consult a qualified attachment
therapist to begin treatment quickly. This is not a comprehensive list,
but focuses on the most easily identified symptoms.
1. Refuses to make eye contact, turns head to look away,
or has blank, shuttered look with no reaction to parents.
2. Dislikes being held and cuddled: stiffens or arches back; pushes parent
away; struggles and wriggles to be put down; fights with hitting, biting
and scratching; does not hold onto parent; prefers being held facing outwards.
3 . Refuses to interact with parents: will not return smiles, imitate
parents, respond to requests to wave bye-bye, kiss, hug etc; will not
play interactive baby games like "pat-a-cake".
4. Lack of affect: passive, limp and unresponsive, withdrawn and silent;
does not cry when hungry, thirsty, has dirty diaper etc; does not seem
to feel pain when hurt. Or the "too good" baby: unnaturally calm, undemanding
and self-contained, content to play alone, does not seek interaction with
others, seldom cries or fusses.
5. Extreme or missing separation anxiety: totally clingy and demanding,
cannot bear to be put down or left alone; aversion to Mom, prefers Dad;
no preference for parents, indiscriminately sociable and charming, goes
happily to any adult and does not turn to look or reach out to Mom; no
age-appropriate stranger anxiety.
6. Excessive crying and raging; chronically fussy, cries most of the time;
intense and easily aroused tantrums.
7. Poor sleep patterns: refuses to fall asleep, wakes frequently to cry
long and hard in the night.
8. Continuing unexplained developmental delays, failure to thrive: does
not gain weight or grow; has poor muscle tone, floppy arms and legs; language
delays - does not babble, not verbally responsive.
9. Excessive and obsessive self-comforting or repetitive behaviors like
rocking back and forth, head banging, hair or ear pulling.
PROMOTING ATTACHMENT IN ADOPTED INFANTS
The following are recommendations from therapists and parents to help
infants with suspected or diagnosed Reactive Attachment Disorder develop
secure attachment to parents Babies with attachment problems may be quite
resistant and unresponsive for a while, and eliciting eye contact, smiles
and cuddles may need a great deal of perseverence from parents. Most parents
will naturally do some of these actvities, but other practices are quite
different from the normal American customs for older babies. New parents
may wish to try them for the first weeks to promote rapid and secure attachment,
and to minimize possible long-term problems, even if the baby appears
to be bonding well. These practices would be beneficial for any newly-adopted
baby. These activities encourage the baby to regress to early infancy,
and experience the situations which build attachment from birth. Parents
recreate the attachment cycle deliberately and intrusively, actively discouraging
the independence and separation which is age-appropriate in normally developing
birthchildren.. They create frequent situations where they interact intensely
with the baby. Parents try to be extremely alert to the baby's signals,
responding quickly and consistently. Parents do not deny that the baby
has suffered trauma, but are empathetic.
1. Ease the trauma of transition as far as possible. In some countries, you can visit the baby in the orphanage several times before taking him or her away, but in others, the baby is abruptly taken and handed over to the parent's care. The total sensory impact of this sudden removal from familiar sights, smells, sounds and textures is often traumatic. Anything you can do to provide continuity can help. Ask about the baby's routines, likes and dislikes. Some parents have been able to send a receiving blanket or soft toy beforehand to the orphanage with their own body scent on it (sleep with it under your nightwear) so the baby recognizes them by smell. Even if washed on return, it will have the familiar smell of the orphanage to comfort the baby. When you receive the baby, leave the original clothing on for the first few hours if possible, keep at least one piece of clothing if permitted (take new clothes to exchange) and keep it, unwashed, in the crib for a few days. Keep the baby on the formula and foods given in the orphanage for at least a few days, and make the transition to new formula gradual. A tape or CD of lullabies or other singing in the baby's native language can calm and comfort the baby. Once at home, an unvarying and predictable daily routine will help your baby feel more safe and secure.
2. Focus on building the relationship with the mother (father if adopting as a single parent, of course). The mother needs to establish her dominance as parent. Only the mother should do the feeding, and should do much of the holding and play. This may seem hard, but this primary bond is crucial for normal emotional development. Let no one else hold the baby except the parents, even at the airport on your triumphant arrival home!! Isolate yourselves with the baby at home for the first week or two, with as few visitors as possible. Do not let visitors hold the baby. Mothers can use the same baby soap, shampoo and lotion, to bond through the baby's sense of smell.
3. Feeding is very important in building attachment. Orphanage babies are usually accustomed to holding their bottle themselves, or may be weaned from the bottle already. Experts strongly recommend returning to bottle-feeding. The mother should always hold the bottle, holding the baby in the classic cuddling position and get eye contact all the time while feeding, if necessary by stroking the baby's cheek, or talking to attract attention. Do not allow the baby to bottle-feed himself or herself. Let the baby continue to bottle-feed this way well into the second year, and beyond if necessary, regardless of the standard advice of pediatricians to stop bottle feeding at 12 months. The baby needs this bonding experience. (clean teeth afterwards to avoid decay in toddlers) When the baby is eating solids, the mother should always feed him or her herself. Do not encourage early independence in self-feeding. Hold the baby on your lap if possible, with eye contact. If the baby must be in a high chair, keep it very close to you, between parents if possible, and touch him or her often, use lots of eye contact and conversation. If the child insists on self-feeding, play interactive, reciprocal feeding games - you put a Cheerio in her mouth, she puts one in your mouth.
4. Lots of physical contact is very important. Orphanage babies are typically severely deprived of physical contact. Hold and carry the baby as much as possible. Cuddle, caress, stroke and rock, gentle wrestling and tickling are fine if not over-stimulating. Use a baby sling or cloth carrier ( Snuggly, etc) to carry her or him facing inwards against your body, wear the baby all day while you go about household tasks. Obviously, you will need to use a car seat while driving, but when you get to your destination, do not carry the baby about in the plastic baby carrier, but hold him or her in your arms, or against your body in a cloth baby carrier. If you do use a stroller, get one that reverses, so the baby faces you. Wear soft clothing without hard belts and buttons. Maximize skin-to skin contact by both wearing short sleeves, holding the naked infant against your bare skin at times and enjoying warm baths or swimming together, or going to infant swimming classes. Massaging the baby with baby oil is very beneficial.
5. Engage in frequent playful interaction with your baby. Do not leave the baby to entertain herself for long periods. All of the traditional "baby games' are great: pat-a-cake, blowing "raspberries", peek-a-boo, counting rhymes with fingers and toes (this little piggie) "riding" the parent's leg, rolling a ball back and forth, imitating the baby's sounds, etc. Play together with baby toys. Swinging in a baby swing is great, if you have the baby face you, and make her look at you and interact with you to get you to swing her again. Therapists strongly recommend using a large mirror for babies who resist eye contact, so that when the baby turns away, she sees you still, cuddling her. Play games using the mirror.
6. Night-time parenting is important, too. Babies with attachment problems should be responded to when they cry in the night. Again, the key is to treat them as newborns. They still need to learn that their cries will always be answered. Mom should stay with the baby as she or he falls asleep, rocking, singing, caressing, etc. Parents should comfort the baby whenever he or she cries in the night. These babies typically sleep in the parents' room, either in their own crib near the parents' bed, or with the parents in the Family Bed ( if you choose this option, be sure to follow all safety recommendations to ensure the baby does not suffocate on or under soft bedding, get lodged between the bed and the wall, or adjacent furniture, or get suffocated accidentally by parents ) Again, this is a situation where others, including your pediatrician, may advise you to teach the older baby to sleep by herself or himself, by letting him or her "cry it out". Leaving a baby to cry is not appropriate for poorly attached infants. When a child seems securely attached then parents may want to encourage the baby to learn to sleep through the night alone. Be sure to eliminate medical causes if the baby's sleep is restless and frequently interrupted by waking and crying: ear infections and lactose intolerance are possible causes of poor sleeping.
7. Holding Time. Many attachment therapists and parents whose children have overcome attachment problems believe this therapy is crucial. This parenting technique was developed by Martha Welch to improve attachment and behavior in normal children, but it has been found to be especially effective in treating RAD, and some adoptive parents choose to resolve attachment issues by beginning to use this method soon after adoption. For further information on this technique, attend our May meeting, or read the book by Martha Welch, Holding Time
RESOURCES: Our May meeting will be on this issue, and handouts will be given out. We will also have a local attachment therapist speak on Reactive Attachment Disorder within the next few months, and I am hoping for a good turn-out for this very important topic! The information for this article was drawn from numerous articles, books and web sites. I have copies of many articles about all aspects of Reactive Attachment Disorder for distribution, at the next meeting, or you can arrange to obtain a set of articles from me. I can also print out a book list for you. (call 882-2516) A great web site on this issue that I used extensively for this article is one focused on adoptions from China, but applicable to any post-institutionalized child. It has many articles you can download, links to numerous other good sites, a book list, resource guide, etc. http://www.attach-china.org When I have enough funds from subscriptions, I will purchase some of the most highly-recommended books on attachment for our lending library. Available from the Greene County Library are: David Hughes, Building the Bonds of Attachment Martha Welch, Holding Time If you are concerned that your child may have symptoms of RAD, there is a group of attachment therapists in Springfield who can evaluate her or him, and provide therapy: Attachment Consultants of the Ozarks, ph. 881-7151. I have a list of other therapists who are not specialists in this disorder,
Jessica sent this to me in July 2000 and generously agreed to have this posted on my website.
[Note: the Attach China List will have references to therapists in your area.]