Attachment Security and Disorganization in Maltreating Families and in Institutionalized Care

Introduction

Children are born with the tendency to establish attachment relationships with caregivers, who provide safety and comfort in times of stress. But not all children are securely attached. Extremely insensitive and maltreating caregiving behaviours as well as instability of care may be among the most important precursors of attachment insecurity and disorganization. Insecure and disorganized attachment, in turn, are predictive of less social competence and more internalizing and externalizing behaviour problems.¹ What do we know about the association between child maltreatment and attachment, what are the mechanisms linking maltreatment with attachment insecurity and disorganization, and what type of interventions might be most effective? 

Subject

Child maltreatment is a widespread phenomenon affecting the lives of many children. According to the World Health Organization, child maltreatment refers to any interaction or lack of interaction reasonably within the control of a parent or person in a position of caregiving responsibility, that does (potential) harm to the child’s health or physical, mental, spiritual, moral, or social development in the context of the society in which the child grows up.² Worldwide prevalence rates of different types of maltreatment ranged from 0.3% based on studies with reports from professionals to 36.3% based on self-report studies.³ 

Attachment disorganization has been suggested to be caused by frightening and extremely insensitive or neglectful caregiving.⁴ Studies with non-maltreatment samples have demonstrated that anomalous parenting, involving (often only brief episodes of) parental dissociative behaviour, rough handling, or withdrawn behaviour, is related to disorganized attachment in the child.⁵ Parental maltreatment is probably one of the most frightening behaviours a child may be exposed to. Maltreating parents do not regulate or buffer their child’s distress, but they activate their child’s fear and attachment systems at the same time. The resulting experience of fright without solution is characteristic of maltreated children. According to Hesse and Main,⁴ disorganized children are caught in an unsolvable paradox: their attachment figure is a potential source of comfort and at the same time a source of unpredictable fright. Moreover, maltreatment leads to increased risks of insecurity: abusive and neglectful parenting are at odds with providing safety and comfort. 

Besides the “family-context” types of maltreatment, we should also think of structural neglect from which world-wide millions of children in institutional care settings suffer. Structural neglect is inherent to institutional care settings that fall short of continuous, stable and sensitive caregiving for individual children due to caregiver shifts, high staff-turnover rates, large groups, strict regimes, and sometimes physical and social chaos.^6,7

Problems

Not all children from maltreating families have disorganized attachments, and there are other pathways to attachment disorganization. Family risk factors such as poverty, substance abuse, low education, and single parenthood may add to the risk of attachment insecurity and disorganization. It is reasonable to assume that parents who are confronted with overwhelming personal or socioeconomic problems and daily hassles may be unable to respond sensitively to their child, or may withdraw from interacting with the child, leading to chronic hyper-arousal of the child’s attachment system. This may impede children’s capacity to develop an organized insecure attachment strategy, even without maltreatment in the stricter sense of the definition. 

Secondly, marital discord and domestic violence may lead to insecurity and disorganization as the child is witnessing an attachment figure who is unable to protect herself, which is highly frightening to a child.

A third pathway to disorganization could be associated with the chaotic environment of institutional care.  Even today, millions of children around the world are brought up in institutional care settings rather than in families. Although institutions vary greatly in terms of their structure and the quality of care provided, what they have in common is instability of caregivers due to staff turnover, the need to provide 24/7 care, and often high child-to-caregiver ratios. For the child this implies that there is no stable caregiver to turn to for consolation in times of stress. Even when sanitary conditions are adequate and nutritional needs are met, the children’s attachment needs are neglected.

Research context

Collecting data on maltreatment samples is difficult. Maltreated children are often victim to multiple forms of abuse,³ hampering a distinction among the effects of different types of maltreatment. Conjoint work with the child welfare system may raise legal and ethical issues involving sharing information with clinical workers or being asked to provide a statement in court.

It is equally difficult to get access to child institutions, and to observe child attachment in those settings. Who is the ‘favorite’ or most stable caregiver of a child? Who should be observed as an attachment figure in interaction with the child? What if the child has not developed an attachment relationship with any of the caregivers? 

Key research questions

Three issues are central: first, does child maltreatment lead to more insecure and disorganized attachments? Second, is institutionalized care also related to insecure and disorganized attachment? Third, are there effective (preventive) interventions for child maltreatment?

Recent research results

A meta-analysis combining all pertinent studies shows that maltreated children are much more likely to have insecure and disorganized attachments, even compared to children growing up in high-risk families (e.g., with single mothers).⁸ Having said that, the cumulation of risk factors is associated with greater risks. Children exposed to five risks factors such as poverty, adolescent mother, low education, single parenthood, minority, substance abuse, are as likely as maltreated children to be disorganized. They may be subjected to some type of parental neglect that is unavoidable in chaotic living and child rearing circumstances.

With regard to domestic violence, Zeanah et al.⁹ documented a dose-response relation between mothers’ exposure to partner violence and infant disorganization. Witnessing parental violence may elicit fear in a young child about the caregiver’s well-being and her ability to protect herself and the child against violence.

In an institution only few children develop a secure attachment relationship with a caregiver: combining all studies to date, 24% of the children in institutions are securely attached (compared to 62% in the normal population) and 57% are disorganized (compared to 15% in the normal population).⁶ Along with huge delays in physical and cognitive development,⁶ these numbers point to the urgent need to promote family-based alternatives to institutionalisation.⁷

An important question, then, is whether children who are placed in a foster or adoptive family after institutionalisation can develop secure attachments with their new parents. Observational studies show that children adopted before 12 months of age were as often securely attached as their non-adopted peers, whereas children adopted after their first birthday were less often securely attached than non-adopted children (but they were more secure than institutionalized children).¹⁰ Adoptees were comparable to foster children. However, adopted children showed more disorganized attachments compared to their non-adopted peers. Again, they were comparable to foster children. 

One might argue that children who leave the institution for placement in an adoptive or foster family are the brighter, more sociable children with a better prognosis than the children left behind in the institution. The Bucharest Early Intervention Project (BEIP)¹¹ is the only study with a randomized controlled design. Following a baseline assessment, half of the institutionalized children were randomly assigned to a foster care program. The other half remained in institutional care. The BEIP also includes a comparison group of typically developing, age-matched children from Romania. At age 4 years, the proportion of secure children in the foster-care group was 24% higher than among children who remained institutionalized, but lower than for the comparison group living with their biological families. Thus, in line with other developmental outcomes,⁶ family care (with adoptive or foster parents) proves to be an effective intervention in the domain of attachment.

How effective are parenting interventions for maltreating families? An umbrella review of interventions to prevent or reduce child maltreatment showed modest intervention effectiveness, both for interventions targeting child abuse potential or families with self-reported maltreatment and for interventions delivered to families with officially reported child maltreatment.² An earlier meta-analysis indicated that programs with a focus on parent training were more effective than programs that solely provided support.¹² 

Research gaps

How do some institution-reared and maltreated children develop secure attachment, and what characterizes these children? Does attachment security constitute a protective factor in high-risk contexts? Does it interact with other protective factors such as the child’s biological constitution or the caregivers’ psychosocial resources? Little is known about the differential effects of the various types of abuse and neglect – co-morbidity may hamper a clear distinction of differential effects. Lastly, the effects of parenting support programs on attachment quality in maltreating samples needs more research. 

Implications for parents, services and policy

From the devastating consequences of institutionalization it is clear that children’s exposure to living in an institution should be avoided completely if possible, and adoptive or stable foster-family care should be supported instead. In a study of HIV-infected children, even compromised family care appeared to be more favorable for the formation of attachment relationships than good quality institutions.¹³ 

Family matters, and some families need support. Maltreatment prevalence data show a large impact of parental experience of maltreatment in his or her own childhood² and risk factors associated with a very low education and unemployment of parents.^2,12 A practical implication of this observation is the recommendation to pursue a socio-economic policy with a strong emphasis on education and employment. Policies enhancing education and employment rates are expected to effectively decrease child maltreatment rates. In addition, combining family-based interaction-focused interventions with large-scale socioeconomic experiments such as cash transfer trials may be a fruitful way to prevent or reduce child maltreatment.²

References

1. Groh AM, Fearon RP, van IJzendoorn MH, Bakermans-Kranenburg MJ, Roisman GI. Attachment in the early life course: meta-analytic evidence for its role in socioemotional development. Child Development Perspectives 2017;11:70-76. doi:10.1111/cdep.12213
2. Van IJzendoorn MH, Bakermans-Kranenburg MJ, Coughlan B, Reijman S. Child maltreatment antecedents and interventions: Umbrella synthesis and differential susceptibility perspective on risk and resilience. Journal of Child Psychology and Psychiatry 2020;61:272-290.
3. Stoltenborgh M, Bakermans-Kranenburg MJ, Alink LRA, Van IJzendoorn MH. The prevalence of child maltreatment across the globe: Review of a series of meta-analyses. Child Abuse Review 2015;24:37-50. doi:10.1002/car.2353
4. Hesse E, Main M. Frightened, threatening, and dissociative parental behavior in low-risk samples: Description, discussion, and interpretations. Development and Psychopathology 2006;18(2):309-343.
5. Madigan S, Bakermans-Kranenburg MJ, Van IJzendoorn MH, Moran G, Pederson DR, Benoit D. Unresolved states of mind, anomalous parental behavior, and disorganized attachment: A review and meta-analysis of a transmission gap. Attachment and Human Development 2006;8(2):89-111.
6. Van IJzendoorn MH, Bakermans-Kranenburg MJ, Duschinsky R, Goldman PS, Fox NA, Gunnar MR, Johnson DE, Nelson CA, Reijman S, Skinner GCM, Zeanah CH, Sonuga-Barke EJS. Institutionalisation and deinstitutionalisation of children I: A systematic and integrative review of evidence regarding effects on development. The Lancet Psychiatry 2020;7(8):703-720.
7. Goldman PS, Bakermans-Kranenburg MJ, Bradford B, Christopoulos A,  Lim Ah Ken P, Agastya NLPM, Cuthbert C, Duchinsky R, Fox NA,  Grigoras S, Gunnar MR, Ibrahim RW, Johnson DE, Kusumaningrum S, Mwangangi FM, Nelson CA, Ott EM, Reijman S, Van IJzendoorn MH, Zeanah CH, Zhang Y, Sonuga-Barke EJS. Institutionalisation and de-institutionalisation of children II: policy and practice recommendations. The Lancet Child & Adolescent Health 2020;4(8):606-633.
8. Cyr C, Euser EM, Bakermans–Kranenburg MJ, Van IJzendoorn MH. Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses. Development and Psychopathology, 2010;22:87-108. doi:10.1017/S0954579409990289
9. Zeanah CH, Danis B, Hirshberg L, Benoit D, Miller D, Heller SS. Disorganized attachment associated with partner violence: A research note. Infant Mental Health Journal 1999;20(1):77-86.
10. Van den Dries L, Juffer F, Van IJzendoorn MH, Bakermans-Kranenburg MJ. Fostering Security? A meta-analysis of attachment in adopted children. Children and Youth Services Review 2009;31:410-421. doi:10.1016/j.childyouth.2008.09.008
11. Nelson CA, Fox NA, Zeanah CH. Romania’s abandoned children: deprivation, brain development, and the struggle for recovery. Cambridge, MA: Harvard University Press, 2014.
12. Euser S, Alink LRA, Stoltenborgh M, Bakermans-Kranenburg MJ, Van IJzendoorn MH. A gloomy picture: a meta-analysis of randomized controlled trials revealed disappointing effectiveness of programs aiming at preventing child maltreatment. BMC Public Health 2015;15:1068-1081. doi:10.1186/s12889-015-2387-9
13. Dobrova-Krol NA, Bakermans-Kranenburg MJ, van IJzendoorn MH, Juffer F. The importance of quality of care: Effects of perinatal HIV infection and early institutional rearing on preschoolers’ attachment and indiscriminate friendliness. Journal of Child Psychology and Psychiatry 2010;51:1368-1376. doi:10.1111/j.1469-7610.2010.02243.x