Volume 1, Number 4 July 2001
Bonding and Attachment in Maltreated Children:
Consequences of Emotional Neglect in Childhood
Bruce D. Perry, M.D., Ph.D.
This article is one in a series developed by the Child Trauma Academy to assist parents, caregivers, teachers and various professionals working with maltreated and traumatized children.
Caregiver Education Series V 3.0, Edited by B.D. Perry. Adapted in part from: "Maltreated Children: Experience, Brain Development and the Next Generation" (W.W. Norton & Company, New York, in preparation)
How do abuse and neglect influence attachment?
There are three primary themes that have been observed in abusive and neglectful families. The most common element is that maltreated children are, essentially, rejected. Children that are rejected by their parents will have a host of problems (see below), including difficulty developing emotional intimacy. In abusive families, it is common for this rejection and abuse to be transgenerational. The neglectful parent was neglected as a child. They pass on the way they were parented. Another theme is "parentification" of the child. This takes many forms. One common form is when a young immature girl becomes a single parent. The infant is treated as a playmate and, very early in life, as a friend. It is common to hear these young mothers talk about their four-year-old as "my best friend" or "my little man." In other cases, the adults are so immature and uninformed about children that they treat their children like adults -- or even like another parent. As a result, their children may participate in fewer activities with other children who are "immature." This false sense of maturity in children often interferes with the development of same-aged friendships. The third common theme is the transgenerational nature of attachment problems -- they pass from generation to generation.
It is important to note that previously secure attachments can change suddenly following abuse and neglect. The child's perception of a consistent and nurturing world may no longer "fit" with his or her reality. For example, a child's positive views of adults may change following physical abuse by a baby sitter.
Are attachment problems always a result of abuse?
No; in fact the majority of attachment problems are likely due to parental ignorance about development rather than abuse. Many parents have not been educated about the critical nature of the experiences of the first three years of life. With more public education and policy support for these areas, this will improve. Currently, this ignorance is so widespread that it is estimated that 1 in 3 people has an avoidant, ambivalent, or resistant attachment with his or her caregiver. Despite this insecure attachment, these individuals can form and maintain relationships -- yet not with the ease that others can.
What specific problems can I expect to see in maltreated children with attachment problems?
The specific problems that you may see will vary depending upon the nature, intensity, duration and timing of the neglect and abuse. Some children will have profound and obvious problems, and some will have very subtle problems that you may not realize are related to early life neglect. Sometimes these children do not appear affected by their experiences. However, it is important to remember why you are working with the children and that they have been exposed to terrible things. There are some clues that experienced clinicians consider when working with these children.
Developmental Delays
Children experiencing emotional neglect in early childhood often have developmental delays in other domains. The bond between the young child and caregivers provides the major vehicle for developing physically, emotionally and cognitively. It is in this primary context that children learn language, social behaviors, and a host of other key behaviors required for healthy development. Lack of consistent and enriched experiences in early childhood can result in delays in motor, language, social and cognitive development.
Eating
Odd eating behaviors are common, especially in children with severe neglect and attachment problems. They will hoard food, hide food in their rooms, and/or eat as if there will be no more meals even if they have had years of consistently available food. They may have failure to thrive, rumination (throwing up food), swallowing problems and, later in life, odd eating behaviors that are often misdiagnosed as anorexia nervosa.
Soothing Behaviors
These children will use very primitive, immature and bizarre soothing behaviors. They may bite themselves, bang their heads, rock, chant, scratch or cut themselves. These symptoms will increase during times of distress or threat.
Emotional Functioning
A range of emotional problems is common in these children, including depressive and anxiety symptoms. One common behavior is "indiscriminate" attachment. All children seek safety. Keeping in mind that attachment is important for survival, children may seek attachments -- any attachments -- for their safety. Non-clinicians may notice abused and neglected children are "loving" and hug virtual strangers. Children do not develop a deep emotional bond with relatively unknown people; rather, these "affectionate" behaviors are actually safety-seeking behaviors. Clinicians are concerned because these behaviors contribute to the abused child's confusion about intimacy and are not consistent with normal social interactions.
Inappropriate Modeling
Children model adult behavior -- even if it is abusive. They learn that abusive behavior is the "right" way to interact with others. As you can see, this potentially causes problems in their social interactions with adults and other children. For children that have been sexually abused, they may become more at-risk for future victimization. Males that have been sexually abused may become sexual offenders.
Aggression
One of the major problems with these children is aggression and cruelty. This is related to two primary problems in neglected children:
The ability to emotionally "understand" the impact of your behavior on others is impaired in these children. They really do not understand or feel what it is like for others when they do or say something hurtful. Indeed, these children often feel compelled to lash out and hurt others -- most typically, someone or something less powerful than they are. They will hurt animals, smaller children, peers and siblings. One of the most disturbing elements of this aggression is that it is often accompanied by a detached, cold lack of empathy. They may show regret (an intellectual response), but not remorse (an emotional response) when confronted about their aggressive or cruel behaviors.
Parents and caregivers make all the difference in the lives of maltreated children. This section suggests a few different ways to help.
Nurture these children
These children need to be held and rocked and cuddled. Be physical, caring and loving to children with attachment problems. Be aware that for many of these children, touch in the past has been associated with pain, torture or sexual abuse. In these cases, make sure you carefully monitor how they respond – be attuned to their responses to your nurturing and act accordingly. In many ways, you are providing replacement experiences that should have taken place during their infancy – but you are doing this when their brains are harder to modify and change. Therefore, they will need even more bonding experiences to help develop attachments.
Try to understand the behaviors before assigning punishment or consequences
The more you can learn about attachment problems, bonding, normal development and abnormal development, the more you will be able to develop useful behavioral and social interventions. Information about these problems can prevent you from misunderstanding the child's behaviors. When these children hoard food, for example, it should not be viewed as "stealing" but as a common and predictable result of being food deprived during early childhood. A punitive approach to this problem (and many others) will not help the child mature. Indeed, punishment may actually increase the child's sense of insecurity, distress and need to hoard food. Many of these children's behaviors are confusing and disturbing to caregivers. You can get help from professionals if you find yourself struggling to create or implement a practical and useful approach to these problems.
Parent these children based on their emotional age
Abused and neglected children will often be emotionally and socially delayed. And whenever they are frustrated or fearful, they will regress. This means that, at any given moment, a ten-year old child may emotionally be a two-year-old. Despite our wishes that they would "act their age" and our insistence that they do so, they are not capable of it. These are the times that we must interact with them at their emotional level. If they are tearful, frustrated, overwhelmed (emotionally age two), parent them as if they were that age. Use soothing non-verbal interactions. Hold them. Rock them. Sing quietly. This is not the time to use complex verbal arguments about the consequences of inappropriate behavior.
Be consistent, predictable & repetitive
Maltreated children with attachment problems are very sensitive to changes in schedule, transitions, surprises, chaotic social situations, and, in general, any new situation. Busy and unique social situations will overwhelm them, even if they are pleasant! Birthday parties, sleepovers, holidays, family trips, the start of the school year, and the end of the school year -- all can be disorganizing for these children. Because of this, any efforts that can be made to be consistent, predictable and repetitive will be very important in making these children feel "safe" and secure. When they feel safe and secure they can benefit from the nurturing and enriching emotional and social experiences you provide them. If they are anxious and fearful, they cannot benefit from your nurturing in the same ways.
Model & teach appropriate social behaviors
Many abused and neglected children do not know how to interact with other people. One of the best ways to teach them is to model this in your own behaviors, and then narrate for the child what you are doing and why. Become a play-by-play announcer: "I am going to the sink to wash my hands before dinner because…." or "I take the soap and get soapy here and…." Children see, hear and imitate.
Use a play-by-play approach
In addition to modeling, you can "coach" maltreated children as they play with other children. Use a similar play-by-play approach:"Well, when you take that from someone they probably feel pretty upset, so if you want them to have fun when you play this game…" By more effectively playing with other children, they will develop some improved self-esteem and confidence. Over time, success with other children will make the child less socially awkward and aggressive. Maltreated children are often "a mess" because of their delayed socialization. If the child was teased because of his or her clothes or grooming, it would be helpful to have "cool" clothes and improved hygiene.
One area in which these children have problems is modulating appropriate physical contact. They don't know when to hug, how close to stand, when to establish or break eye contact, or what an appropriate context would be for picking their nose, touching their genitals, or doing other grooming behaviors.
Ironically, children with attachment problems will often initiate physical contact (hugs, holding hands, crawling into laps) with strangers. Adults misinterpret this as affectionate behavior. It is not. It is best understood as "supplication" behavior and it is socially inappropriate. How the adults handle this inappropriate physical contact is very important. We should not refuse to hug the child and give a lecture about "appropriate behavior." We can gently guide the child on how to interact differently with grown-ups and other children (Why don't you sit over here?). It is important to make these lessons clear using as few words as possible. They do not have to be directive -- rely on nonverbal cues. It is equally important to explain in a way that does not make the child feel bad or guilty.
Listen To & Talk With These Children
One of the most pleasurable things to do is just stop, sit, listen and play with these children. When you are quiet and interactive with them, you will find that they will begin to show you and tell you about what is really inside them. Yet as simple as this sounds, it is one of the most difficult things for adults to do -- to stop, quit worrying about the time or your next task, and really relax into the moment with a child. Practice this. You will be amazed at the results. These children will sense that you are there just for them. They will feel how you care for them.
It is during these moments that you can best reach and teach these children. This is a great time to begin teaching children about their different feelings. Regardless of the activity, the following principles are important to include:
Have Realistic Expectations of These Children
Abused and neglected children have so much to overcome. And, for some, they will not overcome all of their problems. For a Romanian orphan adopted at age five after spending her early years without any emotional nurturing, the expectations should be limited. She was robbed of some, but not all, of her potential. We do not know how to predict potential in a vacuum, but we do know how to measure the emotional, behavioral, social and physical strengths and weaknesses of a child. A comprehensive evaluation by skilled clinicians can be very helpful in beginning to define the skill areas of a child and the areas where progress will be slower.
Be Patient With the Child's Progress & With Yourself
Progress will be slow. The slow progress can be frustrating and many adoptive parents will feel inadequate because all of the love, time and effort they spend with their child may not seem to be having any effect. But it does. Don't be hard on yourself. Many loving, skilled and competent parents have been swamped by the needs of a neglected and abused child that they have taken in.
Take Care of Yourself
Caring for maltreated children can be exhausting and demoralizing. You cannot provide the consistent, predictable, enriching and nurturing care these children need if you are depleted. Make sure you get rest and support. Respite care can be crucial. Use friends, family and community resources. You will not be able to help your child if you are exhausted, depressed, angry, overwhelmed and resentful.
Take Advantage of Other Resources
Many communities have support groups for adoptive or foster families. Professionals with experience in attachment problems or maltreated children can be very helpful. You will need help. Remember, the earlier and more aggressive the interventions, the better. Children are most malleable early in life and as they get older, change is more difficult.