Impact of Early Childhood Attachment Disruptions on Mental Health and Developmental Outcomes
Childhood separations from attachment figures are common and can have lasting implications on a child’s subsequent development and mental health. Attachment disruptions can happen as a result of the incarceration of a parent, death of a parent, military deployment of a parent, divorce, entrance into the foster system, immigration processes, and more. Many of these reasons are a result of policies, hardships, and events that are outside of the family’s control. The loss of a primary attachment figure for a prolonged period of time “represents the loss of everything to a child — a loss of love, safety, protection, even life itself” (James, 1994, p. 7). This loss can shatter a child’s sense of self and cause behavioral and mental health issues that might be attributed by institutions to the individual’s deficiencies rather than relational trauma they experienced as children. In this paper, I will discuss the formation of attachment to early caregivers, the experience of object loss and mourning, the effects on mental health and development, and clinical implications.
Attachment Formation with Early Caregivers
Stern (1985) said that infants can differentiate themselves from others almost from birth, and their primary developmental task is the creation of interpersonal ties with others. Their senses of self develop through interactions with primary caregivers. By their first few months, they can make eye contact, express emotions, distinguish their mother’s scent from another person’s scent, respond to facial expressions, and experience “personal efficacy and a hedonic pleasure when they are recognized and confirmed by their caregivers” (Stern, 1985; Stern, 2010 as cited by Ammaniti & Ferrari, 2013, pp. 367). Observations by Feldman, Greenbaum, & Yirmiya (1999) showed that at 2 months babies and mothers could synchronize their affective behaviors within seconds (as cited by Schore, 2002). A child’s internal objects are constructed from the way they experience themselves in relation to others. For instance, as infants develop the ability to make eye contact, their sense of self develops as adults respond to this ability and gaze back into their eyes (Stern, 1985).
The primary attachment figure serves as a protector, provider, and guide to the child (James, 1994). Attachment is formed through sensory contact — gazing, holding, smelling, and more — between the primary caregiver and the child. The caregiver-child relationship is the holding environment that provides the basis for the development of psychic infrastructure and a sense of security and trust (Winnicott, 1965 as cited by Shapiro & Shapiro, 2006). Securely attached children seek their caregivers when they are distressed and see them as secure bases from which to explore and master the world, whereas insecurely attached children are unable to use their caregivers to regain a balanced emotional state when they become distressed (Shapiro & Shapiro, 2006). As the child develops, they begin to regulate themselves through the internalization of their caregivers as selfobjects (Kohut, 1984 as cited by Schore, 2002).
Bloch and Klein theorize that the primary fear of pre-oedipal children is that they will be eaten or that their caregivers will kill them, stemming from their awareness of their vulnerability and dependence on their caregivers. With healthy attachment, this fear is pacified by the caregivers’ love, but the terror of being eaten alive and/or the feeling that they have to eat someone else in self-defense persists when there is not a secure early environment and trust in caregivers (as cited in Ehrensaft, 2008). When attachment needs are not met, children change their behavior to preserve the attachment relationship. They might try to stimulate their parents’ caregiving behaviors by suppressing their needs, becoming demanding, complying, entertaining, hypervigilant about facial expressions, taking care of the parents, and so forth. Behaviors that are reinforced through a parent’s response and attention are learned and repeated in the future when the child tries to get their needs met (James, 1994; Ehrensaft, 2008).
Object Loss and Mourning
When children are separated from their parents, it’s expected that they will go through a mourning process that ends in the eventual acceptance of the loss or reunification and repair of the relationship if the parent returns. Grief as a response to loss is evolutionarily adaptive because it increases safety and encourages the child to stay close to attachment figures (Bowlby, 1969 as cited by Bravo, 2001). Pathological grief is an inability to accept the loss, express their grief, and go through a healthy mourning process. As a result, the grief becomes repressed in the unconscious and expressed persistently in the person’s behaviors and future pathologies (Bowlby, 1963).
According to Bowlby (1963), there are 4 pathological responses to loss that can result when children are removed from their mothers and given to another caregiver. A perpetual binding to and unconscious yearning for the lost object is the primary dynamic at work, which can show up as lack of affect and alienation. Another response is unconscious anger towards the self, the lost object, or a third party following the loss. After a temporary attachment disruption, reproaches might be useful for ensuring that the object doesn’t go away again followed by repair, but when the loss is permanent the anger is never expressed and affectionate parts of the relationship never return. This anger can show up in aggression towards others or self-harm and guilt. The third response is an absorption with caring for others to avoid experiencing their own grief and sorrow. This projection of their own feelings of helplessness, sadness, and yearning onto other people might cause them to surround themself with people who continuously need support. Normative gender expectations, such as the common scenario of the daughter taking care of her siblings when her mother goes away, might encourage this dynamic. The last pathological response is a complete denial that the object is permanently lost. Adults might shield the child from certain details about the situation or not be able to adequately explain the loss to a young child who has a limited ability to grasp the concept. These children might be unable to experience grief and mourning, forever searching for and fantasizing about the object’s return (Bowlby, 1963).
When children experience attachment disruptions at a young age, they can experience none or many of these pathological responses to mourning that can manifest in unexpected ways that might not seem connected to the loss, especially as time passes or the child enters new environments where the historical context is unavailable. A child who was 2 years old, for instance, developed a strong attachment to a steamroller after her mother left. She didn’t cry or seem concerned about her own mother but was very affected when other children cried. When she saw other children in distress, she demanded that their mothers be brought to them. Factors like the length and frequency of separation, quality of care during and before the separation, age of the child during separation, reasons for separation, emotional and social experience of the transition, and attitude of the new caregiver can affect outcomes (Bowlby, 1963; Shapiro & Shapiro, 2006). When these pathological variants do persist, the child’s object relations can become permanently organized around this pattern, even when the loss is not permanent (Bowlby, 1963).
Impact on Development
Attachment disruptions and interpersonal trauma can affect social, cognitive, and biological development. In observations of infants separated from mothers, Spitz (1946) observed anaclitic depression with symptoms like distress and clinging to observers at first and then a refusal of contact, frequent illness, facial rigidity, motor issues, and insomnia after 3 months. Upon the mother’s return, the babies recuperated quickly. Some infants experienced hospitalism depression after 3 months, where they became completely passive and at 4 years lost the ability to stand, walk, talk, and even live (as cited by Bravo, 2001).
According to Kohut (1980), early caregivers are internalized by the child as selfobjects to meet the child’s needs of mirroring, idealizing, and partnering. When this relationship is disrupted, the child’s sense of self becomes fragmented, which affects developmental tasks that require self-assertion such as toilet mastery, formation of interpersonal relationships, exploration of the world, participation in school, and more (as cited by Bravo, 2001). Infantile coping mechanisms to fear and anxiety such as withdrawal, aggression, hypervigilance, splitting, projection, freezing, and hyperactivity may persist, making it difficult for new caregivers to console them. These defenses help the child regulate their anxiety but make social development difficult (Ehrensaft, 2008; Fraiberg, 1987 as cited by Shapiro & Shapiro, 2006). In some ways these children might act their age, and in other ways they might regress to the age when they experienced developmental trauma. For example, a teenage girl whose mother left when she was 4 might be interested in fashion and boys, similar to other girls her age, but also be drawn to engaging in fantasy play with stuffed animals and tea parties (Crenshaw, 2014).
Recent advances in neurology have shown that the right hemisphere of the brain develops rapidly during the first few years of life, and attachment is linked to right brain activities in regulating the body and nervous system (Schore, 2002). The infant’s emotional awareness and development of self is experienced through sensations processed in the right brain. A mother’s response to an infant’s cry and the exposure to a woman’s face, for instance, activate the right brain (Tzourio-Mazoyer et al., 2002; Lorberbaum et al., 2002; Semrud-Clikeman & Hynd, 1999 as cited by Schore 2002). The right brain also has connections to the limbic system, which affects emotional regulation, adaptation to changing environments, and stress responses in the autonomic nervous system. (MacLean, 1985; Mesulam, 1998; Hugdahl, 1995 as cited by Schore, 2002). The maintenance of a coherent sense of self, the distinguishing self from nonself, and the recognition of family members are functions of the right brain (Devinsky, 2000 as cited by Schore, 2002). Children with PTSD and dissociation have been shown to have right brain abnormalities (de Bellis et al., 2002; Weinberg, 2000 as cited by Schore, 2002). If children are constantly trying to regulate and reorganize their psychological states due early environments that didn’t promote healthy development of their right brain functions, they won’t be able to spend that energy learning and growing (Schore, 2002).
Impact on Psychopathology
Erikson (1950) said that the loss of a mother’s love without substitution can lead to infantile depression and a chronic state of mourning throughout life (as cited by Bravo, 2001). According to Blatt (1974), anaclitic depression during the oral stage stems from a fear of abandonment and being unloved. If children are more developmentally advanced, in the phallic stage or later, when they are separated from caregivers, they will have more intense feelings of guilt because they may have wished for their parents to die during oedipal and their superegos are more harsh (as cited by Bravo, 2001). Earlier losses in the pre-ambivalent phase are tied to depressive psychosis, whereas later losses are tied to more neurotic depressive patterns (Fairbairn, 1940 as cited by Bravo, 2001). In a foster child who was abused by their biological parents, examples of depressive psychotic symptoms were assertions that their adoptive parents were abusive even though they were not and extreme suspiciousness and intolerance of peers (Bravo, 2001).
Children who enter the foster system will likely have more complicated trauma histories than children who experienced a sudden attachment disruption from the death of a parent. These children often experienced a history of abuse and/or neglect from a young age, which resulted in their entry into the foster system. Because their parents might have never been able to attune to them, these children often have difficulties mentalizing or reflecting upon the emotional states of others (Shapiro & Shapiro, 2006). When children are removed from their parents and given to strangers, their yearning for their lost object might be intense, making it painful for new caregivers to bear. There can be strong defensive processes at work on both sides, where the child and new caregivers both collude in the repression and distortion of the loss (Bowlby, 1963).
Repeated separations and rejections in childhood can result in intense ambivalence and increase the likelihood that the child will respond to future losses in a pathological way. Secure attachment is a child’s primary defense from trauma. High level arousal, such as hypervigilance and aggression, in response to overwhelming events is associated with children who have been abused, while low level arousal, such as dissociation and numbing, is associated with children who have experienced neglect (Schore, 2002). When infantile coping mechanisms are used by adults to avoid retraumatization, personality disorders can develop (Kiersky & Beebe, 1994 as cited by Schore, 2002). Borderline personality disorder is associated with early childhood relational trauma and disrupted attachments and is characterized by splitting, emotional dysregulation, and lack of empathy and psychological understanding (Lyons-Ruth & Jacobvitz, 1999 as cited by Schore, 2002).
Depressive symptoms in adulthood can come from a continued yearning for the lost object, a displaced anger towards self in response to the loss, a continual need to care for others while neglecting the self, and/or continued denial of their loss (Bowlby, 1963). Their internalized relational model can lead them to expect separations and loss, and their initial stance to new relationships might be ambivalence, mistrust, and withdrawal (Shapiro & Shapiro, 2006). In fact, according to Brown, Harris, & Copeland (1977), the most significant vulnerability to major depression in adults was loss of a mother before age 11 (as cited by Bravo, 2001).
Clinical Implications
In working clinically with children who experienced attachment disruptions, it’s important to attend to strong transference-countertransference dynamics. The therapist may feel helpless and overwhelmed by the magnitude of the child’s loss, and it’s necessary for the therapist to hold hope, believe in the child’s resilience, and highlight their strengths (Crenshaw, 2014). Involving the family system in therapy with children in these situations is also important because the remaining or new caregivers’ response to the loss and ability to be supportive will affect the child’s outcomes. If children have difficulties attaching to new caregivers and/or exhibit troubling behaviors, new caregivers might feel disappointed and frustrated. The caregivers’ personal histories and/or fantasies about the adoption might also come into play (Shapiro & Shapiro, 2006). In the next few sections, I will discuss three evidence-based family therapies that been developed for children experiencing attachment trauma.
Filial Therapy
Filial Therapy was developed by Bernard and Louise Guerney in 1964 and focuses on enhancing the parent-child relationship. First, caregivers spend 10 sessions being trained as play therapists without their children present. These sessions teach caregivers empathetic listening, acceptance, encouragement, and limit-setting through psychoeducation, observations of other play sessions, role playing, and feedback from the facilitator (Harris, 1997; Myrick et al., 2018). A benefit to enabling caregivers with these skills is that they can integrate them into their parenting practices at home when the therapist isn’t present (Harris, 1997). In community mental health settings, the training can be done in a group setting with other caregivers, which has been shown to be supportive and validating for caregivers (Ashton, O’Brein-Langer, Olson, & Silverstone, 2017). After caregivers are trained, they start to facilitate supervised play sessions with the child with the therapist present and then start to do unsupervised at home play sessions without the therapist. Instead of pathologizing the child and focusing on symptoms, these sessions focus on positive relational shifts, where children can express their emotions, learn coping skills, increase mastery in play, show their strengths, spend quality time with caregivers, and practice positive behaviors (Myrick et al., 2018).
Attachment, Self-Regulation, and Competency (ARC)
The Attachment, Self-Regulation, and Competency (ARC) framework was developed in 2004 to treat children with attachment trauma and is used in 300+ agencies in the United States. The first step in the treatment is to create a structured environment with predictable routines for morning, mealtimes, bedtime, limit-setting, school, and so forth. Caregivers are taught to manage their own affect and attune to the child through psychoeducation, normalization, self-monitoring, modeling from the therapist, and using positive praise and reinforcement for the child with support from the therapist. Once this foundation that creates a sense of safety for the child is built, the therapist works with the child and family to help the child identify, express, and regulate their emotions. Because trauma derails developmental competencies, the child will also likely have developmental goals in therapy. These goals are then addressed to help the child develop a sense of mastery over their environment and positive self-concept (Kinniburgh, Blaustein, Spinazzola, & van der Kolk, 2005).
Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy was developed by Hughes in 2006 as a treatment for foster families with children who experienced abuse or neglect. This type of therapy aims to meet the “child’s need for psychological safety with positive intersubjective experiences” and facilitate a new experience of self (Hughes, 2017, pp. 597). First, the therapist sees the caregiver alone to build a therapeutic alliance, address the caregiver’s attachment histories and trauma, and ensure that the caregiver is committed to caring for the child in new ways. Next, the therapist and caregiver engage in joint sessions with the child, where the therapist facilitates a dialogue for the child to develop a coherent autobiographical narrative that’s not fragmented by terror. The therapist commits to using playfulness, acceptance, curiosity, and empathy. Sessions move back and forth between past and present, differentiating the present from what’s in the past and titrating from lighter to heavier topics to help regulate the child’s affect. Together, the therapist, child, and caregiver co-create new meanings to the child’s life events (Hughes, 2017).
Conclusions
Secure early attachments provide the foundation for healthy development, and disruptions in these attachments can have far-reaching consequences for the child’s mental health, cognitive development, relational patterns, and overall outcomes. It’s important for assessments to have a broad developmental focus so that clinicians can treat the whole person rather than target symptoms in the individual’s diagnosis. When an individual’s behaviors and outcomes are decontextualized from childhood trauma, they can start to look like that person’s personality. When relational trauma is reenacted and passed down intergenerationally, it can start to look like a culture (Menakem, 2017).
While some situations that result in attachment disruptions are inevitable, others are a result of oppressive policies that target groups of people who are not in the dominant identity. On the prevention side, criminal justice reform, foreign policy reform, immigration reform, social support for basic needs (healthcare, food, and housing), and psychoeducation for the general public and policymakers can help reduce cases where primary attachment figures need to be separated from children. On the supportive side, restorative justice practices in schools, use of attachment-focused family therapies, and psychoeducation for teachers and caregivers can help. Mental health, healthcare, criminal justice, educational, and other social support systems need to come together to advocate for policies and practices that are comprehensive and integrative in supporting children and families experiencing this type of relational trauma that carries a legacy that is bigger than what families should be expected to manage on their own. As therapists, we need to hold the dialectics of both advocating for systemic change and maintaining hope for the individual child’s resiliency.
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