The Checkup
By PERRI KLASS, M.D. JUNE 26, 2017
In pediatrics, attachment is the emotional connection that develops between a young child and a parent or other caregiver.
Attachment theory was developed in the mid-20th century by a British psychiatrist, John Bowlby, whose own upper-class British upbringing included the loss of a beloved nanny, and an early trip to boarding school. Mary Ainsworth, his student and later collaborator, devised what is known as the strange situation procedure, in which a 1-year-old is briefly separated from the parent or caregiver, and then reunited, and the behavior during reunions is closely observed.
These experiments, which stressed the child briefly, but then immediately ended the stress, were correlated with in-home observations of parent-child relationships, and researchers built a kind of taxonomy of attachment, reading children’s behavior in the strange situation as an index to the quality of the bond with the parent.
“The reason the strange situation is so important is because early research and repeated studies showed that what parents did at home or in various situations predicted how children behaved in the strange situation,” said Virginia M. Shiller, an assistant clinical professor at Yale University Child Study Center and author of the “The Attachment Bond: Affectional Ties Across the Lifespan.”
A child who has the general sense that the parent is likely to be responsive, she said, is going to ask for attention when the parent comes back in. The child may be upset, but calms down quickly, comforted by the parent, and thereby demonstrates what is called “secure attachment.”
Attachment, said Susan Berger, a developmental psychologist who is associate professor of pediatrics at Ann & Robert H. Lurie Children’s Hospital of Chicago, is about “being sensitive to your child in times of stress so they know if they’re upset, hurt, bothered, somebody will come make them feel better so they can move away and be back in their world again.”
On the other hand, children who have not learned to expect comfort and reassurance when they are distressed will demonstrate what is considered insecure attachment.
“When mom or dad come back in they actually turn away, they might crawl away, they might barely look at mom or dad,” Dr. Shiller said. But that’s not because they’re calm. Studies have shown that these children are also feeling the stress of separation, with high heart rates and elevated levels of stress hormone. In other words, she said, “while one might say, ‘well, that’s just an independent child,’ we have other information that this child is stressed and saying, ‘I’m going to somehow manage this on my own.’”
That kind of stiff-upper-lip, manage-on-my-own behavior has been called insecure-avoidant, in attachment research, while a third group of children, difficult to calm, sometimes aggressively demanding comfort, sometimes angrily pushing the parent away, have been called insecure-resistant. And finally, especially among children who have experienced severe stress, institutional care, and even abuse, researchers identified a pattern they called “disorganized,” in which children seemed to have no consistent strategy for responding to separation and reunion.
Attachment in parenting and child development is not the same as “attachment parenting,” which often stresses the literal physical proximity of parent and child, and the importance of avoiding even minor stresses and separations.
“You don’t have to feel the need to be physically connected to your child every minute of the day and night in order for you to be securely attached to your child and for your child to learn that you’re available to them,” Dr. Berger said.
“It’s a misunderstanding that the more contact you have, the better, so you carry your child around all day, you sleep with them at night,” Dr. Shiller said. “The evidence is more that how you feel about them, how you respond to them is important.”
Why does attachment matter? “The strange situation is in many cases highly predictive of how children will develop their self-confidence, their problem-solving ability, their independence, their language competence, their ability to form social relationships,” Dr. Shiller said. But, she said, “a secure attachment at one year of age does not prevent children from becoming insecure if life events become more stressful.”
For many clinicians, looking at attachment patterns in young children is not to predict their long-term outcomes, but to help parents who may be stressed or struggling learn the kind of responsive, reassuring comforting which will strengthen the relationship.
Dr. Berger teaches residents about the emotional dynamics of children and families, and her research interest is the application of attachment theory in pediatric primary care. She encourages doctors to look at the 1-year-old checkup as a parallel to the strange situation, in which a young child will be predictably stressed, and the doctor can observe the child’s response, and the parent’s.
As doctors, we tend to think about how stressful the visit is for us — that is, how difficult the child is to examine. Dr. Berger developed an observation scale to help residents evaluate whether children are securely attached in the context of the exam room.
“You have a family where the child is running out of the room and the parent is not following them,” she said, “a particularly difficult ear exam and the kid doesn’t even look at the parent, and when you’re done the kid sort of moves away from the parent.” That doctor needs to talk about what happens at home, when the child gets hurt, and needs to help parents find new strategies to comfort and respond.
But looking at 1-year-olds is not to say that their futures are already set. “The research suggests that except for extreme environments, children’s minds are quite plastic, quite flexible,” Dr. Shiller said. In one large study, what mattered most for how socially competent and well-adjusted children looked in the third year of life, she said, was what happened in the second year.
As they grow up, children need to explore the world in a widening circle of strange situations, experiencing what is new and by definition somewhat stressful. They need to move gradually further and further away from their parents, but they need to know they can come back for reassurance and comfort.
“What attachment provides is a secure base for a child to move away from and explore the world,” Dr. Berger said, “and a haven of safety to move back to when the world is too stressful.”