Attachment and Reactive Attachment Disorder in Maltreated Children, Research Paper Example

The Importance of Attachment in Infancy and Early Childhood

The ability of a child to form strong, positive attachments to his or her primary caregivers is a crucial aspect of a child’s development.  Although instances of attachment occur throughout the lives of individuals, the bond that is formed between an infant and its parent (or other primary caregiver) is unique and forms the crux of attachment theory.  Unlike the relationships formed in adulthood, infants and children have an innate need for security and safety which they connect with an attachment figure (Mercer, 2006).  This attachment figure may be a parent or other caregiver; the biological component is less important than the manner in which this attachment figure promotes the necessary feelings of protection and safety.  Although infants, children, and adolescents all have an innate need to feel this type of security, the ability to form positive attachments with caregivers is most important in infancy and early childhood because this children are inherently most vulnerable and helpless at this point (Prior & Glaser, 2006).

Attachment theory was first discussed by John Bowlby in the early 1960s when he evaluated the ability of infants to attach to their caregivers from an evolutionary perspective.  In essence, Bowlby (1988) suggested that attachment is connected to a biological imperative inherent in all humans to ensure the survival of its most vulnerable members.  Attachment theory has special relevance for children whose family situations are unstable or disruptive, especially when these family dynamics lead them to be placed within the foster care system.  As Bowlby (1988) emphasizes, the emotions that surround attachment behavior are intense and all-encompassing, regardless of the age of the children in question.  When attachment is successful, these emotions include joy and a sense of security.  However, when this attachment bond is threatened or broken, a child is vulnerable to intense feelings of jealousy, anxiety, anger, grief, and depression.  The failure to properly attach to a supportive caregiver figure can lead children to exhibit signs of attachment disorders, the most severe of which has become commonly known as Reactive Attachment Disorder (RAD).  There are a variety of therapies and interventions which can be utilized when a child is identified as suffering from RAD.  However, professionals who work with children in foster care must be aware that this is a fairly new area of study and, as such, some methods are more controversial and less accepted than others (Dozier et al., 2001).  However, the successful application of attachment therapies by social workers, physicians, and educators, as well as those therapies which can be employed in the home environment by parents or foster parents, can help to combat the severe effects of RAD in order to demonstrate to children that it is indeed possible to experience security within a family environment.  The ability to form strong attachment bonds is crucial to providing children with stability and a sense of security both in the foster care setting and when preparing children for successful placements in adoptive homes (Hanson & Spratt, 2000).  Thus, an awareness by both professionals and involved family members will help to facilitate long-term placements with a lower likelihood of disruptions, thereby leading to the child’s ability to form healthy and strong relationships well into adulthood.

The Prevalence of Child Maltreatment in the United States

The inability to appropriately attach to a caregiver poses many potential threats to a child’s sense of security, perception of self, and ability to form lasting relationships.  This vulnerability factor is further compounded when a child experiences neglect in the first five years of life and is generally determined by the quality of care a child may receive both prior to and after coming into contact with social service agencies (Prior & Glaser, 2006).  The total number of children in the United States who are neglected or abused is difficult to determine because the manner in which data is collected, analyzed, and distributed varies at both the state and national level (American Humane Association, 2011).  Additionally, research suggests that incidents of child maltreatment tend to be greatly under-reported, with the actual numbers of abused children occurring at more than three times the reported rate (Hornor, 2007).  However, the U.S. Department of Health and Human Services issues an annual report on child maltreatment based on data collected by the National Child Abuse and Neglect Data System (NCANDS) which is generally accepted as a reliable and accurate source of statistical information.  The most up-to-date report currently available is for 2009, and suggests that 12 out of every 1,000 children under the age of 18 were victims of some form of maltreatment (USDHHS, 2009).  More than 75% of this maltreatment occurred in the form of neglect; physical abuse, sexual abuse, and psychological abuse occurred generally at the rate of 10-15%.

Most notably in relation to issues of attachment, the largest group of children experiencing maltreatment were those ranging in age from birth to 1 year, a victimization rate which accounted for 20.6 per 1,000 children of the same age group in the national population, and over 80% of the perpetrators of such maltreatment were the abused child’s parents or primary caregivers (USDHHS, 2009).  The high rate at which very young children are neglected or otherwise maltreated by their attachment-figures illustrates a primary obstacle to helping abused children develop strong attachment abilities, given that their early exposure to attachment is often compromised or severely limited by issues of maltreatment and abuse.  This is doubly compounded because, unlike physical violence, the effects of attachment disorders that stem from early abuse and neglect are extremely difficult to detect and often do not manifest overtly until well into late childhood and early adolescence (Hornor, 2007).

Reactive Attachment Disorder

Reactive Attachment Disorder (RAD) is a relatively new addition to the DSM-IV that has, in the past, lacked clear terminology and an overall consensus in terms of its definition.  However, while it may be referred to as an attachment disorder, an attachment problem, or attachment therapy, RAD is relatively rare in the general population and disproportionately common amongst maltreated children, including those in foster care, kinship care, and the adoption system (Chaffin et al., 2006).  Much of the research into RAD has come from empirical studies conducted within these populations, as well as earlier studies of children of international origins adopted by American families after living in institutional settings (O’Connor & Zeanah, 2003).  RAD can manifest itself within young children in a variety of ways, including the inhibited form of RAD in which children cannot respond to social interactions in a developmentally appropriate manner, and the disinhibited form which finds children relating to others (especially strangers) in an inappropriately familiar manner (Schechter & Wilheim, 2009).  Both the inhibited and disinhibited type of attachment disorders are referred to as RAD in the DSM-IV, and stem from similar issues related to the failure to appropriately bond with caregivers in infancy and early childhood.  In order to be assessed as suffering from RAD, it is not enough for a child merely to exhibit deficiencies in terms of relating to other people.  According to American Psychiatric Association’s DSM-IV, children can only be classified as having RAD when they have experienced poor care in a home or institutional setting which has denied them comfort and stimulation, has disregarded their basic needs for physical and emotional care, or have experienced repeated instability in relation to their primary caregivers, such as a child may experience when moved repeatedly amongst different foster home placements (Hanson & Spratt, 2000).

Schechter & Wilheim (2009) note that children who exhibit healthy and appropriate developmental levels are able to display a preference for specific caregivers and seek and receive comfort from these caregivers during times of distress.  In stark contrast, children with RAD often show no preference for a specific caregiver due to the fact that they have typically lacked a stable attachment figure in their earliest years with whom to develop a healthy and stable relationship (Hall, 2003).  The emotional issues of children with RAD are often compounded by the physical, emotional, and mental effects of maltreatment, neglect, and physical and sexual abuse, making it difficult for social service and health care professionals to assess and intervene on their behalf (Schechter & Wilheim, 2009).  Although there can be some overlap between the emotionally withdrawn/disinhibited manifestation of RAD and the indiscriminate/disinhibited manifestation of RAD, both sets of behaviors carry with them an increased incidence of depressive tendencies, anxiety disorders, and instances of emotional volatility.  However, despite the similar reasons why these patterns may arise in maltreated children, the differences in how they manifest themselves plays a major role in their assessment, intervention, and treatment.  For example, children who exhibit characteristics of the inhibited form of RAD have difficulty displaying affection, responding to the social interaction of others, and regulating their emotions.  This pattern is especially prevalent in children who have been in foster care or institutions, and those who have been neglected by their primary caregivers (Schechter & Wilheim, 2009).  However, while the behaviors of non-attached children share similarities with children who suffer from anxiety and depressive disorder, as well as children suffering from Pervasive Developmental Disorder, those children with RAD are exclusively found in situations featuring extreme neglect and require a distinct intervention and treatment approach from both new caregivers and healthcare and social service professionals (Schechter & Wilheim, 2009).

The disinhibited manifestation of RAD is most prevalent amongst children who have experienced multiple environmental disruptions such as being moved from the parental home through subsequent foster care placements.  This pattern is characterized by an inability to differentiate between strangers and those who are known to the child.  Young children who are well-socialized and behaving at the appropriate developmental level have a tendency to express fear or anxiety when encountering new people; however, children with this form of RAD seek and accept comfort from strange adults indiscriminately (Hall, 2003).  They are also less likely than their well-attached counterparts to ‘touch base’ with their caregiver before wandering off, either alone or with strangers, thereby placing themselves at greater risk due to their lack of discrimination in relation to unfamiliar adults (Schechter & Wilheim, 2009).  Prior and Glaser (2006) suggest that the late development of selective attachment is related to a later development of the fear of strangers and that this fear is further inhibited depending on the number of strangers that an infant or young child may come in contact with.  In children who have experienced abuse, maltreatment, or a high level of caretaker instability, the inability to discriminate between strangers and caregivers is a defense mechanism because the child in question “cannot afford to show interest in any person, even if unfamiliar, as they are potential attachment figures” (Prior & Glaser, 2006, p.222).  The greater the number of caretakers in a young child’s life, the less likelihood there is that the child will be able to form a singular and strong attachment to one person.  Indeed, Prior and Glaser (2006) suggest that the opportunity to form this attachment is time-sensitive, as is the ability to develop the function of stranger-wariness.  Thus, the child’s ability to “beware of strangers, or ‘select out’ unfamiliar figures for attachment behaviour, may never develop” (Prior & Glaser, 2006, p.222), consigning such children to exhibit social disinhibition even once they are placed in a stable and nurturing home environment.

The specific phrasing for these two manifestations of RAD in the DSM-IV seems to imply an either-or situation where a child can be inhibited or disinhibited, but cannot show characteristics of both types of RAD.  As Prior and Glaser (2006) illustrate, the DSM-IV’s stipulation that “reactive attachment disorder can take the form of either inhibited or disinhibited behavior […] presents [these two sub-types] as clearly incompatible” (p.220).  However, Bowlby’s groundbreaking work in regards to attachment theory evaluates the behavior of RAD children differently, allowing for these two forms to co-exist because proximity, comfort-seeking, and acceptance (as in the inhibited formation) and the selectivity of attachment figures and reaction to strangers (as in the disinhibited formation) are all characteristics which are present in well-attached children.  Thus, the logical extension of this is to accept that these characteristics need not be mutually exclusive in children who possess some variety of attachment disorders (Prior & Glaser, 2006).

The Unique Attachment Needs of Children in Care

Overwhelmingly, research into attachment and reactive attachment disorder emphasizes the importance of addressing a child’s attachment difficulties as soon as possible because the ability to form strong bonds with an attachment figure is, to some extent, limited to the first 3 to 5 years of life.  This is not to suggest that children who experience maltreatment and neglect in their early years will be incapable of ever giving or receiving affection, however, parental maltreatment and a lack of caregiver stability has been correlated to later experiences of emotional and psychiatric difficulty amongst children in care (Stovall-McClough & Dozier, 2004).  One of the greatest limitations of much attachment research is the emphasis that it places on studying parental loss amongst children who already possess stable secondary attachment figures, such as in the case of children who lose a parent to death or divorce but already reaped the benefits of forming strong attachments with that parent prior to the incident of loss (Stovall-McClough & Dozier, 2004).  The importance of early intervention is illustrated in research conducted by Stovall-McClough and Dozier (2004) that studied the infant-caregiver relationships during the first two months of placement to determine the ways in which surrogate caregivers can play a pivotal role in helping very young children achieve a sense of security.  Given that many children who come into contact with the foster care system have already experienced difficulties in achieving secure attachments to their biological caregivers, and that these relationships are often compounded by issues of neglect, maltreatment, and abuse, such children have already become “caretaking causalities” (Stovall-McClough & Dozier, 2004) prior to even entering care.  Stovall-McClough and Dozier’s research demonstrated that the younger children were when they entered into care, the less difficulty they had in adapting to their new environment and the more likely they were to form attachments to their foster parents.  This was especially true when the foster parents were sensitive to their needs, both as infants and as children with complicated emotional histories, and tended to result in the formation of relationship patterns which showed evidence of secure behavior and a minimal amount of avoidant behavior (Stovall-McClough & Dozier, 2004).  These results were echoed in similar research conducted by Dozier and colleagues (2001) which found that the attitude of the foster parent played an even greater role in successful attachment than the age at which a child came into care, findings which emphasize the need for continued education for both social service professionals and foster parents in relation to the important role that they play in promoting successful attachment in children who have previously experienced familial disruption.

Zeanah and colleagues (2004) conducted a related study in which they evaluated the characteristics of RAD in almost 100 toddlers who had been in foster care for at least 3 months.  Their research found that siblings were likely to demonstrate similar behaviors in relation to attachment, an unsurprising result given that sibling groups would likely share the same pathogenic parental experiences.  Zeanah and colleagues (2004) also noted instances of both inhibitive and disinhibitive RAD characteristics from individual children, a finding which supports Bowlby’s (1988) conclusion that RAD can take a variety of formations depending on the unique set of circumstances experienced by an individual child.  Although it can be difficult to fully assess the number of children who are affected by RAD within the population of children in foster care in the United States, studies have suggested that although RAD may only manifest itself in less than 1% of the general population, it becomes much more prevalent within high-risk populations such as children who have come into contact with the foster care system (Hornor, 2007).  Indeed, research conducted by Zeanah and Emde (1994) of one specific American county evaluated the behavioral characteristics of all children  under the age of 4 entering into foster care because of abuse or neglect.  Their study found that 38% of these children showed signs of RAD, although not all of them met the diagnostic criteria of the DSM-IV.

Such findings have major implications for social services at both the policy level and for professionals who work with maltreated children.  Clearly, attachment disorders are a dominant issue for children entering into care, and may be exacerbated when children are moved repeatedly between foster homes or shuttled repeatedly between foster care and parental care (Lieberman, 2003).  Given that one of the root causes of attachment disorders is a lack of stability from parental figures, it is crucial that social service professionals actively work to find placements for these children in which the foster parents are aware of the full range of potential behaviors that they may encounter when caring for children with RAD.  In such a way, social workers have the potential to curb the cyclical patterns of loss and instability often encountered by children with RAD through the promotion of strong fostering relationships in which the surrogate attachment figures also strive to create a supportive and nurturing environment which promotes the development of attachment between foster parent and foster child (Lieberman, 2003).

Attachment Therapies:  Accepted Interventions

The successful treatment of RAD is dependent on an accurate and detailed assessment conducted by a trained psychotherapist.  Indeed, many of the difficulties encountered in some of the more controversial approaches to treating RAD stem from the insistence by adherents that attachment issues stem from a child’s primitive feelings of rage, emotions which must be physically and mentally broken down in order to prevent said child from acting out against caregivers, peers, and society at large (Institute for Attachment & Child Development, n.d.).  Although RAD is statistically rare, especially in the general population, RAD has become a popular diagnosis for parents and caregivers who are seeking explanations for the difficult or antisocial behavior of children in their care.  Chaffin and colleagues (2006) emphasize the importance of receiving a diagnosis of RAD from trained professionals (as opposed to self-administering one of the many checklist tests available on the Internet, for example) because there are a number of issues related to family instability and the uncertainty associated with living in a variety of foster care settings which could also result in RAD-like behaviors amongst certain children.  It is crucial to refrain from that all children in care suffer from attachment disorders as there are a number of other factors which may cause behaviors similar to RAD amongst children who have experienced trauma or pathogenic care, including the stress that occurs in transitioning from a home environment into a foster care setting.  This is also true when evaluating children who are involved in international or cross-cultural adoption placements because cultural differences and the stress of this transition can also manifest itself in ways similar to those seen in legitimate attachment disorders (Chaffin et al., 2006).

However, once an attachment disorder has been diagnosed, there are a number of ways in which social workers, educators, and health care professionals can contribute to a successful intervention.  Much of the research literature which is aimed at healthcare professionals emphasizes the need to take a three-tiered approach to treatment so that interventions encompass the evaluation, diagnosis, and treatment of the parent, the child-parent relationship, and the child with the main focus being on the manner in which attachment disturbances have affected the social and emotional development of these three distinct ‘patients’ (Schechter & Wilheim, 2009).  While this may be feasible in situations where social services has not already intervened, or in situations where the eventual goal is to return the child to his or her parents, the reunification of families is not always possible.  Indeed, many of the issues which result in a child’s placement in foster care, such as parental incarceration, drug abuse, domestic violence, and maltreatment, may preclude the opportunity for developing healthy attachments between parent and child, at least in the short-term (Lieberman, 2003).  Thus, the energies of social workers conducting interventions might be better spent on developing solutions for the individual children under their care by helping to facilitate attachment between the child and the foster parent through ensuring stable placement environments and the continued education of foster parents in regards to the foster child’s specific emotional, physical, and mental needs (Zeanah & Emde, 1994).

Educators, both in the school and daycare settings, and clinicians can assist in developing a child’s sense of security in order to promote the ability to attach by working in partnership with all members of the treatment team, including social workers, foster parents, and the child himself.  When developing a treatment plan, it is crucial for all team members to keep in mind the underlying concepts of attachment, including the child’s need for safety and comfort, the role that instability and fear play in undermining attachment, and the child’s need for reliable and secure routines that also allow for individual exploration and self-discovery (Simms et al., 2000).  To this end, it is crucial for social service professionals to create a strong network of social support for both foster parents and foster children.  This will assist in developing a supportive alliance between foster parent and foster child while also helping to build the foster child’s social-emotional development through the recruitment of community, familial, and therapeutic social support systems which will assist in nurturing the development of alternative modes of attachment (Simms et al., 2000).

Hornor (2006) notes the importance of using the core principles of attachment theory when working with children who demonstrate characteristics of RAD.  Such methods include creating caregiver and environmental stability, utilizing patience and consistency, and creating behavioral models which reinforce the child’s need (whether overtly expressed or not) for safety and nurturance.  The American Association of Child and Adolescent Psychiatry (AACAP) suggests that the long-term prognosis for children with RAD is an area which has been largely understudied, with much of the research in this area being devoted to children who have spent their formative years in institutions rather than those children living in foster care placements (2005).  However, in the case of both children entering into adoptive placements from institutional settings and in children living in foster care, AACAP recommends a prolonged period of observation prior to treatment in order to determine the types of relationships experienced by the child in relation to his or her primary caregivers as well as others who he or she interacts with on a regular basis (peers, siblings, other foster children, etc.).  Observational data can be used in conjunction with a detailed history of the child’s comfort-seeking patterns, behavior with strangers, and other attachment related behavior to determine the best course of action for the individual child.  AACAP (2005) stresses that the relationship between the caregiver and child “forms both the basis for assessment of RAD symptoms and the nexus for treatment of RAD” (p.1213), and will serve as a point of comparison when evaluating the child’s relationship with other individuals.  Based on the concrete observations of the clinician, it is then possible for treatment plans to be developed that can help to establish supportive attachment relationships between the child and his or her caregiver where there might have been none previously (AACAP, 2005).  As first discussed by Bowlby (1988), any therapist looking to work with non-attached children must first provide the child with a secure base through which the child can engage in further explorations of himself and others.  Such a base can be understood to mean both the relationship between child and therapist and the relationship between child and caregiver; thus, when beginning attachment therapy it is especially crucial for social service professionals to ensure that the foster care placement is a secure and solid one that is unlikely to be disrupted, since the need to move a child from one placement to another during this process is likely to counteract any progress made in the creation of secure and safe bases (Dozier et al., 2001).

Attachment Therapies: Controversial Interventions

Perhaps because of the lack of concrete research concerning the effective treatment of RAD in foster children and adopted children, there exists alternative conceptions of attachment therapy for children in this specific population.  According to Chaffin and colleagues’ (2006) report conducted on behalf of the American Society for the Prevention of Abuse to Children (ASPAC), these controversial therapies are often primarily rooted in clinical observations and do not build off of a foundation in attachment therapy like many of the more accepted methods of treatment.  In this approach, RAD characteristics do not merely develop in the wake of maltreatment, abuse, or parental loss but can stem from any traumatic event experienced by a child, including frequent child care changes, ear infections, and colic (Chaffin et al, 2006).  The experience of adversity results in children, especially when non-verbal, becoming “enraged at a very deep and primitive level [that results in a child’s inability] to attach or be genuinely affectionate to others” (Chaffin et al., 2006, p.78).  Unlike traditional attachment theory, which remains rooted in developing nurturing relationships between the child and an attachment figure (Bowlby, 1988), this alternative approach tends to view the relationship between the child and their attachment figure as one which is conflicted and adversarial.  According to this theory, suppressed or unconscious rage inhibits a child’s ability to form positive relationships with others and may lead to aggressive and violent actions towards parental figures or others in the family dynamic (Institute for Attachment & Child Development, n.d.).  The power struggles that emerge from a non-attached child’s desire to control their environment and relationships are, in this theory, rooted in a need for dominance and emotional and psychological manipulation on the part of the child.  Proponents of this conflict-based approach suggest that children with attachment disorders have a high likelihood of engaging in amoral, dangerous, and antisocial behaviors if they are not placed in treatment.

Unsurprisingly, perhaps, those who promote this type of attachment therapy disavow the validity of more traditional approaches and “commonly assert that their therapies, and their therapies alone, are effective for children with attachment disorders and that more traditional treatments are either ineffective or harmful” (Chaffin et al., 2006, p.78).  They reason that attachment therapy is unsuccessful because non-attached children are incapable of establishing the trust-based relationship with a caregiver that traditional attachment theory holds to be so crucial.  Many of these controversial treatments set up a dynamic between caregiver and child in which the child is assumed to be in control of the relationship and is depicted in a variety of negative terms including manipulative, deceptive, self-centred, and lacking a conscience (Institute for Attachment and Child Development, n.d.).  In this modality, treatment strategies include breaking down a child’s resistance in order to undermine any sense of superiority or control that the child may believe he or she possesses.    In this type of therapy, parents or other caregivers may be counselled to assert total control over every aspect of the child’s life so as to break down the character flaws which prevent a child from successfully attaching.  This may take the form of assigning hard labor or meaningless tasks to the child, removing them from school or other social contacts, and monitoring their food and water intake (Chaffin et al., 2001).  Additionally, these controversial therapies often employ catharsis and other techniques in order to allow the child an outlet for their suppressed rage.  It is in this area that such forms of attachment therapy have received a great deal of attention, primarily because a number of child deaths in the United States have been linked to this form of therapy.  For example, rebirthing and coercive holding are meant to demonstrate to the child that they lack control and that all of their needs can be met by the adults in their lives; however, such therapies have, in the worst case scenarios, resulted in the suffocation deaths of children, and in the best case scenarios merely expose children to further instances of trauma without helping them to develop successful or supportive attachment to their caregivers (Chaffin et al, 2001).

Implications of Attachment for Foster Children and Adopted Children

Current research in the field of attachment emphasizes the major importance of identifying, assessing, and treating attachment disorders as early as possible, citing the need for early intervention as a key to a child’s ability to form successful attachments with primary caregivers.  However, maltreated children often do not come to the attention of social service and health care professionals during the earliest years of their lives when treatment might be most effective.  This does not preclude the ability of children to develop the ability to attach to a caregiver or parent, but does suggest that alternative courses of action may need to be further researched and developed in order to help such children find other ways of achieving security and emotional closeness with their caregivers.  Maltreated children often have difficulty expressing their emotions in socially-acceptable ways, which can lead to frustration and anxiety amongst caregivers, be they foster parents or adoptive parents.  Thus, it is crucial that the caregivers of children who exhibit characteristics of RAD receive education and support from health care and social service professionals that will prepare them for some of the psychological and behavioral problems they are likely to encounter in children who lacked a reliable and consistent attachment figure in their earliest years of life (Lieberman, 2003).

One of the primary means to accomplishing successful attachment amongst maltreated children, from a social service perspective, is to limit the number of transitions that a child is forced to undergo by helping to ensure that a child is placed in a supportive and nurturing foster home where the surrogate parents are well-aware of the unique needs of maltreated children who may exhibit characteristics of RAD.  Additionally, further research is needed to determine the role played by neglect and abuse in determining the long-term success of children in care in developing strong attachments with non-parental figures (Hornor, 2006).  In effect, the large number of risk factors found in many children in care–including abuse, drug exposure, and disruptions in care–often compound attachment disorders, indicating that it is necessary for all members of the care team to work together in order to determine the best possible course of action for the individual children in their care, with an overall awareness of the ways in which positive and supportive attachment can be developed in both the short and long term.  Although much of the current research is not specific to the needs of children in care, the overall foundation of attachment theory in emphasizing a child’s need for stability, security, and nurturing caregivers who do not change over time may offer the best solution for identifying and treating RAD in maltreated children.  Despite the potential allure of quick-fix solutions offered by more controversial therapies, these alternatives should not be an option for individuals who wish to instill a sense of love, respect, and stability in maltreated children.  As demonstrated by Chaffin and colleagues'(2006) findings for the ASPAC, social service professionals and others who work with maltreated children must show an intense level of sensitivity when dealing with a population who have already encountered substantial neglect and abuse.  Thus, any treatment system which advocates a negative perception of maltreated children as manipulative or dangerous is counterproductive in helping them to achieve a sense of trust in the adults around them (Chaffin et al., 2006).

Indeed, a true resolution of attachment disorders can only come with time and the recognition that children in care face a host of unique difficulties which must be addressed in order to help them develop a strong sense of self and the ability to give and receive love and nurturance from the adults responsible for their care.  It is vital that all of those who work with maltreated children recognize that “for children who have not known love, learning that they are wanted does not come automatically:  it calls for conscious and deliberate teaching on the parent’s part.  ‘Good enough’ parenting is often not good enough for an emotionally disturbed child” (Lieberman, 2003, p.282).  This assertion, while applicable to biological or adoptive parents, is also sound advice for health care professionals, social service workers, and foster parents; indeed, any one who seeks to improve the attachment abilities of maltreated children needs to remain acutely aware that all of their behaviors, whether positive or negative, stem from an inability to accept and understand that they are valued, loved, and cared for.

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