The following article is the introduction to
Facilitating Developmental Attachment: 
The Road to Emotional Recovery
and Behavioral Change
in Foster and Adopted Children
by Daniel A. Hughes. 
Copyright 1997 Jason Aronson Inc.
          All children, at the core of their beings, need to be attached to someone who considers them to be very special and who is committed to providing for their ongoing care.  Children who lose their birth parents, especially those who have experienced the trauma of abuse and neglect, desperately need such a relationship if they are to heal and grow.  Providing psychological treatment to such children is a challenge, a responsibility, and an opportunity for great professional satisfaction and personal joy.  However, if the child in treatment is not experiencing an attachment to a parent, whether because of lack of ability or opportunity, the therapist is greatly limited in her efforts to assist the child in beginning to heal and in wanting to work to become "special" to self and others.
          When these children fail to form an intense attachment to a parent, their developing sense of self is experienced as being bad and incomplete and their autonomy develops in a very limited and fragmented manner.  They are very likely to experience deep shame, intense rage, pervasive anxiety, and extreme isolation and despair.  They are also likely to manifest a variety of destructive and self-destructive symptoms whose functions are to attempt to make life bearable when it is lived outside the basic reality of interpersonal relatedness.  When, as adults, these children do attemt to develop intimate relationships with others, they often experience much conflict, heartbreak, jealousy, violence, and abandonment since they lack the abilities needed to become intimate with another.  They relive, alone and in very compulsive ways, the abuse and/or neglect that they lived as children.  On those occasions when we have the opportunity and ability to facilitate both a basic attachment between a child and parent as well as the development of a positive and well-integrated autonomous self, we live with the knowledge that the child now has a chance to adequately pursue happiness and success within the human community.  These children now have the most fundimental skills necessary to break the generational cycle of abuse.
          Stopping the abuse is not enough.  The results of the abuse often live on within the child and render him unable to take advantage of the new opportunities presented to him.  Many children enter foster care or are placed in an adoptive home and then proceed to prevent their parents from enabling them to develop in healthy directions.  These children often make their new parents' love, support, guidance, and directions ineffective and permeated with stress, conflict, and disillusionment.  Why do they not take advantage of the opportunities given to them within these good families?  Why do they continue to work so compulsively to recreate the circumstances of abuse and neglect that they experienced in the past?  Too often we have "saved" these children from abuse, but we have failed to encourage their healing.  We have failed to show the child how to respond positively in a relationship with a parent.  We have failed to show the parent how to structure the relationship so that the child is more likely to become meaningfully engaged.  With these children, our primary responsibility is to provide them with the opportunity for an attachment to a caring and capable parent and then to focus all our energies on successfully facilitating this attachment.  Within this context, the child has the means of developing a sense of self that is both positive and competent.
          Let me briefly list qualities common to many of these children that make it very difficult for them and their new caregivers to establish a positive, reciprocal relationship:

            1)  They work very hard to control all situations, especially the feelings                  and behaviors of their caregivers;
            2)  They relish power struggles and have a compulsion to win them;
            3)  They feel empowered by repeatedly saying :No!";
            4)  They cause emotional and, at times, physical pain to others;
            5)  They strongly maintain a negative self-concept;
            6)  They have a very limited ability to regulate their affect;
            7)  They avoid reciprocal fun, engagement, and laughter;
            8)  They avoid needing anyone or asking for help and favors;
            9)  They avoid being praised and recognized as worthwhile;
          10)  They avoid being loved and feeling special to someone; and
          11)  They are enveloped by shame at the origin of the self.

          Certain factors cause the development of these qualities.  These factors, which need to be explored and understood if we are to uncover ways of facilitating the child's readiness to form an attachment to his new parent, include the following:

            1)  Repeated abuse and neglect leads to an anxious and disorganized                  attachment that creates a poor working model for both the developing              self and for subsequent attachment relationships.
            2)  This poor working model creates chronic vigilance and lack of trust in               future caregivers.
            3)  This poor working model creates a sense of self as "bad" -- a self that               becomes limited and fragmented in physical, affective, behavioral,                    and cognitive development.
            4)  The loss of birth parents is unresolved; the child is not able to                           establish new relationships and must compulsively reenact the loss.
            5)  Early experiences of a reciprocal mother/child dialogue are minimal;                  the self is both unaware of the realities of attachment and has weak                 internal skills needed to become engaged in one.
            6)  Early socialization experiences are characterized by humiliation,                        terror, and rejection.  There is intense opposition to new socialization               experiences.
          Increasingly we are realizing that a healthy infant and child develop as part of a primary attachment to a caregiver.  The existence of this attachment constitutes the womb for the "psychological birth" of the infant.  Increasingly, too, we are realizing that an individual's healthy identity requires the presence of relatedness with others as much as the presence of individuation.  The "working model" for our manner of relatedness, evolving over the first four years of life, is our first attachments to the primary caregivers in our lives.  It reflects the developmental patterns (as described by Stanley Greenspan 1988) which define the nature and qualities of our physical, affective, behavioral, and cognitive development.  From this model, we define our basic communications, comfort, empathy, identifications, conscience, caregiving, and styles of relating to the various individuals in our lives.  When the initial working model is insufficient for the full development of these qualities, every effort must be made to provide other models of sufficient emotional depth, behavioral variation, and cognitive meaning for the child to utilize in order to proceed with his development.
          This task of facilitating attachment to new caregivers is rendered more difficult by the pervasive working model distortions caused by abuse and neglect.  These children perceive caregivers as violent, cruel, rejecting, and unpredictable.  Safety is increased through avoidance, silence, denial of one's own feelings and thoughts, lying, manipulation, and developing an attitude of constant vigilant control over one's environment.  This working model does not include any reality of mutual enjoyment nor does it include accepting the caregiver's socialization expectations as the best means to remain safe and to develop with a balance between individuality and relatedness.  This working model also involves the child seeing himself as bad, lazy, selfish, mean, and probably stupid. He sees himself as incapable of and undeserving of enjoyable experiences and loving relationships.
The following article is the introduction to
Facilitating Developmental Attachment: 
The Road to Emotional Recovery
and Behavioral Change
in Foster and Adopted Children
by Daniel A. Hughes. 
Copyright 1997 Jason Aronson Inc.

This page was last updated on: 18 October, 2005

          When the child with a weak attachment interacts with a seemingly caring and giving adult, the child assumes that it is his own successful manipulation that is causing the adult to act in a caring way rather than any nurturing quality of the adult or any intrinsic worth of the child.  When the adult disciplines him, he interprets the discipline as abuse, rejection, and humiliation, further proof that caregivers are not to be trusted, and the need to rely on manipulative control of others becomes greater.  Thus, the new parent's caregiving does not facilitate trust.  Adults who "give" the most are seen as those who are easiest to manipulate rather than as those one can trust.  Acts of nurturance from parents are often seen as means to control parents rather than opportunities to become attached.  If these parents want to "give" to the child, the child is quite willing to take advantage of the situation for his own self-focused reasons that have little to do with relatedness.
          These children are often drawn to new adults, who are easier to charm and manipulate, rather than to their foster or adoptive parents, who are beginning to make realistic demands on them.  The child's affection is often indiscriminate since it does not represent a developing attachment but rather a means of controlling an adult, any adult.
          Within a healthy attachment, discipline is a fact of life.  The child may grumble, but he accepts the fact that one parental role is to teach.  He has a basic trust that this teaching (though at times annoying), is ultimately given in his best interests.  Discipline leads to his socialization and helps him move from the healthy narcissism of the infant to the engaging mutual relatedness of the preschool child.  The healthy child's working model for parent-child relations incorporates the value of such teaching into all aspects of his developing identity.  It is a model for behavior, skill development, values, and interests.
          The child who is poorly attached to a caregiver views discipline as arbitrary, cruel, and rejecting.  When discipline is not perceived as actually abusive, it is probably seen by the child as neglecting his wishes and needs and being deeply humiliating at the core of the developing self.  It represents the child's failure to adequately manipulate and control the adult, leaving the child feeling more vulnerable to future abuses beyond his control.  He does not see that discipline is directly associated with his behavior nor that it is in his best interest.  Rather, it is proof that this adult, too, is cruel.  The adult's other "nice" behaviors were deceitful.
          Affection, discipline, and mutually enjoyable communication and activities emerge naturally within a healthy parent-child attachment and, in turn, further intensify and develop this attachment.  A great variety of emotions emerge naturally within this relationship.  Joy and anger, sadness and excitement, affection and anxiety all come and go within the profound security of a basic attachment.  The toddler does feel shame when limited and this serves a healthy purpose in early socialization experiences when it is not associated with disgust and rejection.  As he continues to develop, conflicts are resolved, wishes emerge, and separate interests are pursued.  Every activity is colored by the attachment.  The child discovers that he can develop himself as a worthwhile and competent individual without sacrificing the basic attachment to his parent.  He does not have to sacrifice his autonomy in order to try to satisfy his basic attachment needs.
          Regretfully, affection, discipline, and mutually enjoyable interactions are much less successful in achieving these ends for children who are poorly attached to their caregiver and who possess a working model that emerges from profound abuse and neglect.  The parents who attempt to raise these children quickly discover that their parenting skills are not very effective.  Their love is rejected, misinterpreted as weakness, and used against them.  The child may well take advantage of their love as a way to hurt or control them.  Discipline is misinterpreted, strongly resented, and resisted.  Mututally enjoyable activities that the child cannot control are rejected and turned into battles.
          Poorly attached children try to control everything in their daily interactions with their caregivers.  This compulsive need to control functions to manage their unmet needs for both attachment and autonomy.  Since they do not feel attached to their caregivers and thus cannot feel safe through their relationships with them, their only means of trying to establish a sense of safety is through successfully controlling whatever happens.  At the same time, this frantic control is manifested as constant oppositional and/or avoidant behaviors that represent their primary maladaptive means of trying to meet their developing autonomy needs.
          The majority of children who enter foster care or who are placed for adoption are able to make the transition to their new homes successfully with traditional social and mental health services.  They do manifest the ability to attach to their new homes despite various past traumas.  This book is focused on the smaller group of foster and adopted children who have disorganized, insecure, and disrupted attachment histories and who lack the ability and readiness to form a secure attachment with their new parents.  When such children are placed in foster homes, they immediately prove to be a profound challenge to the skill, caring, and commitment of their new foster parents.  These parents often work harder with their poorly attached child than they ever did with their other foster or birth children.  They believe, and are often told by professionals, that love and patience will be enough.  They seek assistance and find waiting lists, a series of helpers involved in career or job changes, and counseling and recommendations that do not effect meaningful change.  Having begun with an idealistic desire and an actual passion to make a difference in the lives of a few traumatized children, they often drift toward discouragement and self-doubt.  They blame themselves for not getting through to their child.  Often, with considerable guilt, they finally ask that the child be moved to another home.  Tragically, this sequence occurs for countless foster children.  For many of these children, it happens over and over.
          It is in these situations that intensive therapeutic interventions are required.  These interventions must make use of the parents' commitment, basic skills, and own capacity for attachment.  They must demonstrate very directly and intensely to the child how much the parents have to offer him and how totally he needs these parents for his own basic psychological development and survival.  These interventions must engage and enhance the child's physical, emotional, behavioral, and cognitive traits if he is to learn to use this opportunity to form a healthy attachment.
          To be effective, the child must be engaged by the therapist at the level of preverbal attunement rather than in a setting of rational discussions.  The therapy must also involve a great deal of physical contact between the child and the therapist and parent.  During much of the most intense therapeutic work, the child is being touched or held by the therapist or parent.  His intense emotions are received, accepted, and integrated into the self.  Within a therapeutic atmosphere based on attunement, he is able to begin to explore aspects of himself and his relationships with his parents that have previously not been accessible.  The development of both the child's attachment to his parents and his integrated self is the primary goal of the therapist; all else is secondary.
          In traditional child therapy, the child's relationship with the therapist is the critical foundation for change.  This relationship develops trust between the child and therapist, and the trust then allows the child the freedom to explore trauma, work through conflict, integrate troubling experiences, and so forth.  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 relationship is too circumscribed and brief and it lacks the crucial quality of 24-hour-a-day engagement that a parent has with a child.  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.
          These children, in fact, show their capacity to manipulate the therapist by providing some disclosures in order to insure that the therapist will allow the sessions to proceed according to the child's wishes.  They "give" the therapist some of what they know she wants in order to be able to do what they want.  They benefit little from such disclosures.  These children also learn in therapy that there are advantages to recalling the abuses of the past because they make great excuses for their present disruptive, aggressive, or defiant behaviors.  Once a child lacking a secure attachment learns that adults respond with sympathy to accounts of abuse, his motivation to accept responsibility for his current behavior decreases unless this tendency is directly and forcefully dealt with in the treatment.  Even then, it may remain a problem since he is often good at finding other adults who will accept past abuses as legitimate reasons to maintain present distorted perceptions and inappropriate behaviors.
          In psychotherapy with children who have attachment problems, parents need to be present and actively involved in the sessions.  The parent-child attachment is the central therapeutic goal.  The relationship between the child and therapist is certainly important as well, especially in so far as it serves as a "working model" for the child's relationship with the parent.  The parent's presence enables the therapist to model crucial ways of engaging for both the parent and child.  There is frequent shifting between the therapist-child relationship to the parent-child relationship in any given session.  The parent becomes a co-therapist in important ways.
          In psychotherapy, all aspects of the child's relationship with the parent are explored.  Love and fun and also conflict and discipline have equal weight.  Since love and fun tend to consistently decrease in families with poorly attached children, they must begin to increase in therapy and then both parent and child must learn ways to facilitate and protect that experience in the home.  The child's fears of love and fun are explored and his means of sabotaging these experiences are uncovered.  Activities to build love and fun are developed and ways of maintaining or reestablishing love and fun during conflict and discipline are also found.
          Discipline is explored, discussed, and reenacted in order to frame the child's response to discipline as evidence of his difficulty with trusting the parent and with accepting the self rather than as evidence of the parent being mean or of the child being bad.  Above all else, discipline must be structured so that it does not break the developing engagement between the parent and child.  The child may misbehave in order to avoid any emerging attachment.  He may also misbehave in order to control the parent's emotional reactions.  Misbehavior may reflect his intense ambivalence about attachment.  The parent must respond in such situations in ways that build, not weaken, the attachment.
          The child's difficulty with trusting the parent is explored, discussed, and reenacted.  It is related in part to his perception of discipline as being abusive.  He generalizes constantly from his experiences with the abusing parents to experiences with his new parents.  A differentiation between the old and the new is made in many ways over a variety of family life situations in order to begin to reduce the generalization.  Helping the child differentiate the old from the new parent is critical if he is to begin to trust the new.  Framing misbehavior, discipline, conflicts, and parental authority as important aspects of the child's learning to trust is a critical component of therapy and psychological movement within the child.  Otherwise these issues simply represent "behavioral management," which is difficult to experience for the child who is full of shame and is convinced that he is not worthy of trust.  Such children resist any encounter that would facilitate the experience of mutual parent-child trust.
          Treatment of children with attachment problems must be intensely engaging if the child is to become receptive to a new and emotionally rich way of relating to his parents.  Many instances of delight, anger, fear, and sadness -- expressed through yelling, whispering, crying, and laughing -- occur during the sessions so that the child remains engaged with the therapist and parent and experiences a deep, positive, reciprocal interaction.  The therapist constantly directs the child to the parent for expressions of permission, sorrow, gratitude, fun, surprises, conflict resolutions, and so forth.  Parents hold, rock, hug, and tickle the child, not in an artificial prearranged way, but as a natural part of the sequence of interactions.
          Another crucial aspect of the psychological intervention is facilitating the parent-child interaction outside of the treatment session.  This is too crucial to be left to parent-education classes or support groups.  These interactions must be integrated with the treatment interactions.  The therapist needs to demonstrate to both parent and child a general framework for raising a child who has significant difficulty with attachment.  She must also suggest numerous specific ways to relate with the child in day-to-day situations.
          This book presents a framework for therapeutic interventions with children who show significant difficulty forming and maintaining an attachment to their primary caregivers.  Much of this work focuses on children who were abused and/or neglected by their birth parents.  Most often these children did not return to their birth parents and so were left with the task of developing attachments with their foster and/or adoptive parents.  Many of these interventions might also apply to children who are with their birth parents but for various reasons have weak or maladaptive attachments with them.  However, the interventions assume that the parents with whom the children are learning to attach do themselves show the ability to engage in appropriate attachments with children and demonstrate a level of psychological health superior to that of their children.  These children cannot and should not be expected to work for and take risks toward becoming attached to adults who are not able or willing to interact with the child in a competent and committed manner.
          Regretfully, as is true with much of the psychological treatment of children (Kazdin 1993), there is little supporting research for these treatment interventions.  Most of the research on the psychological treatment of children does not focus on the treatment of abused and neglected children.  Research often focuses on cognitive-behavioral interventions in treatment programs in university settings.  I have done what most clinicians do in their practices, namely, study, read, talk with other clinicians, review and develop my own framework and techniques, observe the results, and then begin the process of learning again and again.
          When I use the term attachment I am referring to the unique relationship between a child and his parent that facilitates the healthy developmental patterns that require such a relationship.  Such a relationship does not occur with the child's therapist, teacher, or other potentially important adults in his life.  Just having a relationship with a parent does not insure that the child is "attached" to her.  Attachment refers to the unique relationship between child and parent through which the child is able to proceed with the major qualities of his own psychological development.
          Stanley Greenspan (1988, 1989) refers to developmental attachment patterns that emerge, in sequence, through the child's relationship with his parent and his own psychological state over the first 4 years of his life.  The child who has had a weak and disorganized attachment with his parent during part or all of those first years manifests many significant problems in his developmental attachment patterns.  To have a chance for a good life, he must be able to form a secure attachment with his new parents and develop healthy attachment patterns that facilitate his affective, behavioral, and cognitive development.
          This work is motivated in part by my convictions formed over my first 15 years of psychological practice that traditional interventions of play therapy, parent education, and cognitive-behavioral techniques are not sufficient to effect significant progress with the poorly attached child.  Although traditional interventions are often effective with foster and adopted children who have positive and stable working models of relationships and of the self, they are much less so with the poorly attached child.  I have seen many children who never benefited sufficiently from these interventions to be able to begin to live well within the human community.  I have also seen many foster and adoptive parents give overwhelming blood, sweat, and tears to these children without having a significant effect on their child's ability to benefit from these gifts.  This work is written with the hope that others will become more aware of this tragedy and more committed to the search for ways to provide meaningful assistance.
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