Adopting Children with Attachment Problems

Daniel A. Hughes This article describes children with significant attachment problems and summarizes the actions needed to increase the probability that such children can be successfully adopted. Healthy and disordered attachment patterns are detailed, as well as the principles and strategies that are important in parenting such children and the parenting characteristics that should be sought in selecting families for children with attachment disorder. Psychological treatment and other postadoption services necessary to support the adoption and the child's ability to successfully form a secure attachment with the adoptive parents are also highlighted.

Daniel A. Hughes, Ph.D., is a psychologist in private practice. South China, Maine.

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successful adoption presupposes that the adopted child will gradually, and yet in a timely manner, develop a secure attachment with his or her new family. Most children are, in fact, able to form such bonds and the resulting attachment becomes the foundation for both their integration into the family and for their ongoing psychological development. Certain children, most often following months or years of severe neglect and abuse as well as multiple placements and caregivers, develop gaps in their development that impede their readiness and ability to form attachments with their adoptive families, no matter how loving and committed those families are. To facilitate the ability of such children to become a part of families, adoption professionals need to understand and develop specialized programs for them. The behaviors and needs of children with attachment problems challenge the professionals responsible for them. After interviewing and observing a particular child, and describing him or her as being friendly, charming, affectionate, and engaging, an evaluator may often conclude that the child is able to form an attachment with adoptive parents. The author, however, used similar adjectives in describing an 8-year-old girl whom he evaluated a number of years ago. This girl left him confused and troubled when she asked if he could arrange for her to move from foster home to foster home every three monthsher idea of an ideal life. Those evaluating children for adoption need to be aware of the observations and findings of professionals and researchers studying children in institutionalized settings. In 1937, Levy described one such child as being "superficially affectionate and charming" [Levy 1937]. Almost three decades later, Provence and Lipton [1962] described many children in orphanages as "indiscriminately friendly." About the same time, Ainsworth [1961] described children with a history of maternal deprivation as overly friendly and "socially promiscuous." A child who initially is

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friendly and engaging can easily lead prospective adoptive parents into assuming that he or she wantsand is able to accept a reciprocal and positive parent-child bond. Adoption professionals must understand and communicate to prospective parents that such friendliness may indicate the child has difficulty establishing selective attachments. Children with significant attachment problems manifest fairly typical behavioral patterns, which, in turn, tend to elicit fairly common responses from their parents. Such children may have little or no understanding about what constitutes a parent-child bond or the interest a parent has in acting upon the child's best interests. They don't understand that their parents' enjoyment of and commitment to them is far deeper than their own particular words or actions. Such children are often friendly with anyone since they have found such friendliness to induce most adults to be "nice." By smiling and being charming, they control the situation, and, to a large part, the behaviors of the adults. The child determines, without thinking, what is best for him or her and believes that the task is to get the adult to do as he or she wants. For children with significant attachment problems, the adultchild relationship itself is of little interest. It does not occur to children who lack an understanding of the parent-child relationship that adults would try to understand what was best for them and then meet their needs. As a result, these children assume that the adult must be manipulated or intimidated. Once the adult has given the child what he or she wants, there is little desire for a relationship with the adult until the next wish comes along. If an adult grants many wishes and then says "no," the child will have little use for that person and will try to find another adult who will provide what is desired. If no other adult is present, the child will turn back to the first adult and, aware that charm did not work, will try to wear the adult down through intimidation, angry outbursts, threats, and defiant behaviors. If that fails, the child will punish the adult for being "mean," usually by stealing

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or breaking things or by doing things meant to make the adult angry and upset. The child essentially is saying, "You made me unhappy, so I'll make you unhappy too." In the typical case, parents of such children begin the adoptive placement by saying "yes" many times to try to build trust and reassure their children that they truly want to meet their needs. They overlook many situations in which a "no" might be indicated, hoping that, once the child's wishes have been met often enough, the child will accept the rules and expectations that are a part of living in their home. These children, however, will not learn to accept the rules because they are focused on taking care of their own wishes and have little empathy or concern for their parents or the interests of the rest of the family. When children with attachment problems do not begin to show any reciprocal interest in the family, parents begin to blame themselves and question their decisions and parenting capacities. After a time, they blame their children and come to believe that they are wanted by their children only for what they will provide at a particular moment. They despair that their children will ever want a positive, reciprocal, parent-child bond, a despair grounded on the realities of attachment problems. Children with serious attachment problems are unaware of what is missing in their relationships with their parents. Even if they were aware of this missing aspect of the relationship, however, they would not choose to work for such a relationship. Entering into a reciprocal parent-child relationship would require them to give up the control and self-reliance that have enabled them to survive years of neglect and emotional isolation. This article delineates an approach that adoption professionals and programs can use to lessen the likelihood that the above scenario will occur. Professionals must understand healthy developmental attachment and the effects on children when it fails to occur. Prospective adoptive parents also must understand a particular child's attachment problems and, in conjunction with

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adoption professionals, decide whether they have the ability and motivation to adopt such a child. Parents who make the decision to adopt must receive training in parenting the child so they can maintain the emotional stability of their home while slowly facilitating the child's ability to form an attachment with them. They and their child will need specialized treatment that facilitates this process and a range of postadoption supportive services. The disruption of an adoption does not necessarily mean that the child had significant attachment problems. Adoptions disrupt for a variety of reasons. The adoptive parents may not have engaged in good parenting because of factors that have nothing to do with the child: there may have been a poor match between the child and family; or the child may have manifested disruptive testing behaviors during the initial months of the placement that may reflect anxiety about forming an attachment rather than problems forming an attachment. The nature of a child's attachment-related behaviors should always be identified by a qualified professional to determine whether the child's functioning represents significant attachment difficulties or other factors.

The Development of Attachment

Normal Developmental Attachment During the first year of life, infants are social beings whose sensory systems focus on interacting with their primary caregivers. The child's mother easily senses how much attention her infant needs and joyfully and repeatedly offers it to him.* She touches and holds him, moves and rocks, sings, smiles, and uses exaggerated facial expressions and "babytalk" to communicate her emotions. During such interactions, which some researchers have called "attunement" (referring to the sharing of affect between
* The feminine and masculine genders are used here for ease of reading and are not meant to imply that fathers do not form attachments with their infants, or that male children develop attachment disorders at a higher rate than female.

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mother and infant), the infant's brain is stimulated, positive emotions of interest and joy develop, and the child begins to feel special [Stern 1985; Schore.1994]. During the first year, the child increasingly prefers his mother and becomes selective in his choice of adults with whom to relate. He also discovers that interactions with certain adults are the source of much meaning and enjoyment in life. In contrast to the first year, when the mother teaches her infant that he is special, during the second year, the mother teaches her toddler that other members of the family are special as well. She begins to actively socialize her child by saying "no," channeling his behaviors, setting limits, and not responding to all of his wishes. When she frustrates her child's wishes, he feels shame, which is the mother's primary socialization intervention [Schore 1994]. During these interactions, there is no attunement and the toddler avoids eye contact, tries to hide, and becomes motionless and speechless. This experience of shame causes emotional distress, which the mother intuitively recognizes. She reattunes with her child with a smile, touch, or supportive word, and reassures him that he is special but also that he must be aware of the rights and feelings of others. Within moments, the toddler feels special again as his mother has comforted him in his distress, which she had caused by saying "no." Begirming in the second year and well into the third year, the young child, within the safety of this secure attachment, learns to integrate both attunement and shame as well as his own wishes and the demands of socialization. He learns how to remain close to his mother, the source of both pleasure and distress. As he learns to accept fully the "good" and "bad" mother as the same person, he learns to integrate and accept the "good" and "bad" parts of himself. This integration is crucial if he is to internalize all features of his mother and incorporate his attachment to her into his developing sense of self [Mahler et al. 1975]. The child develops the ability to consistently feel empathy, tolerate frustrations, regulate his emotions, control his behaviors, and recognize the differ-

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ence between right and wrong. He becomes aware of and able to articulate his thoughts and feelings and begins to soothe himself. As he "downloads" his parents' love into his developing self, he trusts that they will do what is best for him and will keep him safe. A secure attachment and a well-integrated self are two sides of the same reality, enabling the child to feel that he is special. Securely attached, he can proceed with the developmental tasks that lie ahead [Greenspan & Lieberman 1988]. Over the past 50 years, the importance of attachment in the parent-child relationship has been studied extensively [Karen 1994]. Attachment theory, which originated in the work of John Bowlby and Mary Ainsworth, has come to refer to the role of attachment in both healthy psychological development and in developmental psychopathology [Bowlby 1988; Ainsworth 1978]. Attachment is thought to have a central role in future relationships and psychopathology because the original parent-child bond is believed to provide the working model for all subsequent meaningful relationships [Cicchetti et al. 1995]. The readiness and ability to engage in reciprocal, enjoyable relationships throughout life is based on the countless attunement experiences that occur during the first few years of life. The ability to experience and resolve conflict is based on early experiences of shame that are followed by reassurance and reattunement with primary attachment figures. The ability to integrate the need for intimacy with the need for autonomy depends upon how successfully the individual internalizes primary attachments into early identity development. Given its central role in early psychological development, it is easy to see why a secure attachment is thought to be central in a child's developing ability to regulate emotions, control behavior, and establish an integrated sense of self [Schore 1994]. The Effects of Abuse and Neglect on Attachment Child abuse and neglect have been shown to greatly impede the development of secure attachment [Crittenden & Ainsworth

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1989]. Increasingly, the central factor in the intergenerational transmission of childhood maltreatment is thought to be disorders of attachment [Cicchetti 1989]. Difficulties in establishing and maintaining a secure attachment with one's primary caregivers are likely to exist on a continuum from mild to severe. Many children who have been abused, neglected, and/or subjected to multiple caregivers have symptoms that may not meet the full diagnostic criteria for significant attachment disorders, yet they may manifest various characteristics that reflect a disorganized, anxious-ambivalent, or anxious-avoidant attachment with their primary caregivers [Crittenden & Ainsworth 1989]. Other children manifest severe difficulties with related attachment. The developmental sequence that characterizes a secure attachment contrasts significantly with that of a child who experiences chronic neglect, abuse, and placement with multiple caregivers. Often, the maltreated child does not discover that he is special; does not learn the joy and interest that is elicited from experiences of shared affect with his mother; and does not feel affirmed, identified, or important. Instead, he increasingly feels isolation and sadness and may eventually feel despair and that there is little to live for. Because his basic needs for food, warmth, and physical comfort are most likely not consistently met, his interests increasingly turn to meeting these fundamentals. He lacks confidence in his own developing abilities and in his parents, whom he sees as not concerned with his best interests. Eventually, the child discovers options that may help get his needs metscreaming at, charming, or manipulating others to somehow "make" them do things for him, or finding ways to get what he needs on his own. He becomes increasingly self-reliant, rejecting the urge to be supported and comforted, and chooses instead to try to control his environment. The maltreated child is also shamed constantly, first with nonverbal messages that his parents have little interest in him, and

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then by rejection when he begins to be mobile and to elicit his parents' rage [Schore 1994]. He quickly learns to dissociate himself from the intense shame and his profound feelings of worthlessness and to deny the shame. He withdraws into fantasy and/ or obsessive plotting about controlling the future, and places the source of his pain outside of himself, assuming a "tough guy" attitude and/or that of an "innocent victim." The child becomes increasingly successful at concealing his pain and his vulnerability, first from others and then from himself. Pervasive shame becomes a major part of the child's existence as his shame "experiences" are seldom followed by reassurance and comfort [Schore 1994]. Gradually, he begins to resist others' efforts to comfort him and learns to deny feelings of wanting to be nurtured and comforted. He experiences what little comfort he can through controlling others, causing them distress, learning to manipulate and intimidate, and acquiring objects in which he has little interest. When a child with this background is invited into an adoptive family and offered the opportunity to have a positive reciprocal relationship with someone who wants to meet his needs, he is likely to be confused and frightened. He begins to reexperience feelings from his infancy, i.e., the wish for attunement that never was fulfilled, as well as pervasive shame, but he quickly minimizes and denies these feelings. The child rejects the affection and playful interactions that are offered because he feels vulnerable and has no confidence they will last. He also rejects routine socialization and discipline because he associates discipline with feelings of intense shame. Because of his past experiences, he is not interested in a reciprocal relationship or in mutual enjoyment and shared responsibilities. A child without a history of secure attachments is likely to develop a variety of symptoms that reflect an isolated and painful developmental path: little empathy for others, limited awareness of the consequences of his behavior, little guilt and remorse, difficulty expressing thoughts

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and feelings, and poor discrimination among relationships. The regulation of bodily functions, emotions, and behavior may be poor, with much variability among situations and experiences. At the same time, the child often has an excessive need to control every situation. Reactive Attachment Disorder When a child manifests most of the above symptoms to a significant degree, he may meet the diagnostic criteria for Reactive Attachment Disorder (RAD). This disorder is defined as "markedly disturbed and developmentally inappropriate social relatedness in most contexts, begirming before five years of age." RAD may be characterized as either "inhibited" or "uninhibited." In the inhibited type, social interactions are "excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses;" in the uninhibited type, the child manifests "indiscriminate sociability" without "appropriate selective attachments" [American Psychiatric Association 1994]. As yet, there is no clear evidence that one type of attachment disorder is more severe than the other. It is also not clear whether most children with RAD manifest both types to some degree. At present, differentiating between the two types of RAD does not have implications for treatment or prognostic considerations. Many children who have been abused and neglected manifest attachment problems to some degree, although they do not meet the criteria for Reactive Attachment Disorder [Cicchetti 1989]. An assessment of the severity of a child's attachment problems should include a description of the child's specific symptoms as well as answers to the following questions: 1. How severe, chronic, and pervasive were the child's experiences of neglect and abuse? 2. How many caregivers did the child have? (Disrupted relationships with foster parents are each likely to be experienced as rejection and abandonment. With each subsequent disrup-

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tion, a child's readiness to form an attachment with the next caregiver is likely to be less.) 3. Were there any positive, continuing relationships during the first two years of the child's life? 4. Has the child begun to show any significant improvements in his current family foster home? 5. Is there any selectivity in the child's attachments? 6. Has the child ever shown grief over loss? 7. Does the child accept help and comforting? 8. Can the child enjoy, without disrupting them, close and playful interactions that are similar to the attunement interactions mothers have with their infants? 9. Does the child ever directly show shame over his behaviors? 10. Does the child ever show sadness over the consequences of his behaviors, rather than being enraged over their perceived unfairness? 11. Can the child experience and give expression to sadness and to fears? The Right Match If a child has not shown signs of developing a secure attachment with a caregiver, it cannot be assumed that he will begin to do so when given the permanency of adoption, but neither can it be assumed that he will not do so. Professionals working with the child should neither falsely promise positive results to prospective parents nor conclude that the child is hopeless. Instead, they should strive to understand the child's attachment problems and to help the adoptive parents choose a child with whom they are well matched. The decision to adopt a child with significant attachment problems is one that should be made only with full knowledge about the child and after much deliberation. The adoptive parents should receive information on all aspects of the child's history and symptom patterns; have opportunities to speak to the child's

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foster parents about the nature of their relationships with him and whether these relationships have changed over time; be helped to assess how the child's symptoms and needs may relate to their own personalities and desires; and be given a realistic appraisal of the challenges that they will face and the skills they will need to parent the child. Professionals should help the parents to understand that key skills include the ability to regulate their own emotions, deal with their child's rejection of them without taking it personally, and relate to their child with affection and empathy w^hile remaining firm and persistent in socializing the child. Parents also must have the ability to remain committed to their child even if he fails to make significant progress in his ability to develop a secure attachment with them. Finally, the adoptive parents should be provided with appropriate training, support, and treatment services to help them maximize their child's ability to securely attach with them.

Parenting Principles and Skills

When parents are able to help their child develop a secure attachment for the first time in that child's life, they are facilitating the "psychological birth" of their child. To reach that goal, however, parents must recognize and overcome numerous conflicts and challenges. Parenting children with significant attachment disorders requires the ability to engage the child in a manner that facilitates the same type of shared affective experiences other parents have with their infants. A parental attitude that communicates empathy, acceptance, affection, curiosity, and playfulness increases the child's ability to respond to the parent in the same marmer as would an infant who was securely attached. This parental attitude, which is communicated when the parent places limits on the child, allows the child to tolerate the shame that discipline elicits and lessens the likelihood that the child will react with rage.

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Because this attitude is not easy to maintain in the face of continuing oppositional behaviors and angry outbursts, parents must be able to regulate their own emotions and not allow their child to control them. They must be able to express anger in response to specific behaviors in a quick, direct manner, and then follow that expression with reassurances and comfort. Parents should not take personally their child's rejection of their discipline and affection. Often, it is necessary to begin an adoptive placement by keeping the child in close physical proximity to his new parents so they can make many of his choices for him and provide him w^ith a sense of safety. The child can begin to rely on his parents to decide which behaviors represent the best choice for him in the new setting. This results in fewer consequences for misbehavior because there are fewer misbehaviors, and the child is not repeatedly engaged in experiences of failure and shame. This level of physical presence may need to be present for weeks, or even months before the child will begin to internalize the choices, wishes, and values of his parents. Most children with attachment problems, however, do adapt to this level of parental presence. As the parents begins to give the child choices and unsupervised time, he is likely to initially make poor choices and respond to limits with oppositional behaviors and/or angry outbursts. Through the use of natural and logical consequences, parents can accept the child's choices and provide him with empathy for the consequences, striving to be "sad for" his distress over the consequence rather than being "mad at" him for his behavior. If, however, the child repeatedly engages in the same misbehavior, consequences may need to be more comprehensive and of longer duration than is customary in raising children without attachment problems. Increased limits on the child as a natural and logical consequence may be needed to prompt the child to abstain from the significant misbehaviors. When given with empathy and acceptance, natural and logical consequences are not pu-

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nitive or rejecting and do not put a child at risk of reexperiencing the abuse and rejection that characterized his original insecure attachments. A child who repeatedly misbehaves is unlikely to respond to positive reinforcement, increased activities with his parents, or the receipt of concrete objects. The best response to constant misbehavior is to give the child the opportunity to be physically close to his parents once again, as his behavior signals that he is not ready for independence and freedom of choice. This required closeness should be explained with empathy and acceptance, and with assurances that eventually the child will have the opportunity for greater separateness. Psychological Treatment of Children with Significant Attachment Problems Strategies based on traditional treatment principles are not likely to be effective with children who have significant attachment problems because of the nature and severity of their psychological problems and deficiencies [Hughes 1997; James 1994; Levy & Orlans 1998]. Traditional therapy presupposes that the child has the readiness and ability to form a therapeutic relationship that can be utilized to resolve past traumas and form a more stable and positive sense of self [Greenspan 1989; Hughes 1997]. Children with significant attachment problems are not likely to enter into a relationship with a therapist that would facilitate such progress, as they are likely to attempt to manipulate or intimidate others, and a trusting relationship is not likely to develop. Thus, allowing the child to set the pace and direction, as is customary in traditional therapy, will lead to continuing avoidance. The pervasive sense of shame that characterizes these children's psychological status will generate intense resistance to routine therapeutic efforts; such children are likely to dissociate from negative affective experiences as a result. Additionally, because

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traditional therapy sessions do not routinely involve parents, they fail to incorporate a crucial factor in facilitating a parent-child attachment. Therapy for children with significant attachment problems should be structured to replicate the attachment sequences that characterize normal developmental attachment. The sequence of attunement, socialization/shame, and reattunement must be the central therapeutic experience. With a primary emphasis on parent and therapist attunement with the child's ongoing affective states, the therapist should work to elicit and share positive affect with the child and provide the child with an opportunity to experience surprise and delight in response to the adults' active engagement with him. The child should be helped to feel safe and tolerate the affective intensity that is generated. Once the child achieves some level of comfort and relaxation, the therapist should actively engage the child and help him explore the sense of shame he has associated with both earlier experiences of neglect and abuse and current experiences of discipline and frustration in his adoptive family. Often, children strongly resist becoming engaged with the therapist and their parents and exploring their feelings of shame, fear, rage, and despair [Hughes 1997; Levy & Orlans 1998]. The therapist must work with this resistance, empathizing the difficulty of the work, and should approach the resistance with acceptance, playfulness, and curiosity. The therapist may be the person who initially voices the realities of the child's early experiences of neglect and abuse, and should do so with empathy and understanding for the intense affect this information generates within the child. If the child is to become ready to develop a secure attachment, the therapist and the child's parents must support and comfort him as he gradually faces these issues. Frequently, parents and/or the therapist will touch and hold the child as he becomes engaged in the stressful and intensely emotional work. Physical contact may serve the same purpose as

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the mother who spends so much time holding her infant. When an adult (the therapist or the parent) holds the child, the adult is attuned to the child's affective states and creates a "holding environment" that provides the child with the security he needs [Hughes 1997,1998; Levy & Orlans 1998]. "Holding therapy," a form of attachment therapy, has generated some controversy. In early forms of this therapy, the therapist provoked the child into a rage, then held the child against his will [Hughes 1998]. Many questioned whether the child was being retraumatized through this form of "holding" and whether a "trauma bond" was being formed [James 1994]. Today, most therapists who hold the child or have the parent hold the child will first explain the intervention to the child and elicit the child's consent [Hughes 1997, 1998; Keck 1995; Levy & Orlans 1998]. "Holding" then takes place in an environment of support and nurturing that facilitates the child's ability and readiness to become engaged in difficult therapeutic work. The parents' presence in therapy is crucial. By being present, they can provide their child with emotional support, attunement experiences, and safety during the stresses of treatment; help the child to differentiate them from the abusive and neglectful parents in his past; and provide the child with the opportunity to learn that he does not have to conceal his past from his parents. The parents can model how to express thoughts and feelings, and reassure their child about his worth in spite of his past experiences and current behaviors. Parental participation in therapy enables the therapist to understand how the child is functioning at home, and provides an opportunity to "check out" the child's perceptions and to reinforce the parents' authority to the child. Significant attachment problems tend to be quite resistant to therapeutic change [Hughes 1997; James 1994; Leyy & Orlans 1998]. As a result, a long period of time is often needed for attachment therapy to facilitate an attachment that will have a major influence on the child's functioning. When a child's attachment

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problems are mild, the child may respond to the specific interventions of attachment therapy in less than six to nine months. More often, 18 to 24 months are required before significant progress is achieved. Even then, some children, either because of the severity of their early abuse and neglect or because of neurological or constitutional factors, do not achieve the gains necessary for them to develop a secure attachment.

Other Postadoption Services

Children who resist forming attachments with their parents present their adoptive families with intense, ongoing challenges. For new parents to facilitate attachments with their children, they need considerable support within the adoption communitysupport that is tailored to meet the unique needs of the poorly attached child and his family. Support groups for adoptive parents of children with attachment problems can be of considerable benefit [Hughes 1998; Keck 1995; Levy & Orlans 1998]. Often, other parents have the greatest understanding of the difficulties and stresses associated with raising children with attachment problems, and are best able to offer support and guidance on parenting interventions that proved to be effective with their own children. Other parents readily understand that the problems of children with attachment disorders are intense, real, and longstanding. Respite services should also be provided for adoptive parents who are trying to meet their child's intense needs. Respite care provides parents with time to relax and focus on their own interests and on other relationships. The respite care provider should understand the nature and severity of the child's attachment problems, should be aware of the adoptive parents' rules and expectations, and should be willing to follow those guidelines. The respite care provider must also be able to anticipate that the child may portray his parents as mean and unfair through

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lies and half-truths. The respite care provider must understand the important of making clear to the child his or her support of and confidence in the child's parents. Finally, in-home supportive services, provided by mental health or family support professionals or paraprofessionals for a few hours each week, should be available to give parents a respite and enable them to continue providing an intense level of parenting during the remainder of the week. For such services to be helpful, however, in-home workers need to function as parental assistants who reinforce parents' judgments, rules, and authority to the child. They must understand the nature of attachment problems and the interventions that are appropriate. Many in-home workers are trained to employ traditional behavioral management techniques. Such techniques, however, are likely to be ineffective with children w^ho have attachment problems. If children with attachment problenrs and their adoptive parents are not provided with appropriate services, the risk of adoption disruption increases, as does the possibility that the children will never achieve the security and support of a permanent adoptive family [Keck 1995; Levy & Orlans 1998]. Children with attachment problems are at high risk for frequent moves among foster homes and other care settings. Under such conditions, the attachment problems the children have when they enter out-ofhome care are likely to intensify and become more pervasive. Children who do not achieve secure attachments with significant caregivers in childhood are likely to manifest various forms of psychopathology during adolescence and adulthood, and are likely to have serious problems developing and maintaining attachments with their spouses and children. Conclusion A high level of skill and commitment is required when an adoption agency places a child who manifests significant attachment

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problems. Adoptive placements should be carried out in a thorough, professional manner document the nature and severity of the child's attachment problems. Adoption professionals should make the prospective adoptive parents fully aware of the child's problems, the services that the child requires, and the services that may be needed in the future, as well as the parenting qualities that must be brought to bear to facilitate the child's readiness and ability to form an attachment. Finally, appropriate treatment and supportive services must be available to the family. Neglect and abuse may cause psychological problems that go far beyond traumatic stress. Chronic neglect, which has been called the "trauma of absence," can cause significant gaps in the development of the self. These gaps become evident when a child has great difficulty in understanding the joy and satisfaction that comes from a secure attachment with his parents. A child with attachment problems needs the opportunity to learn how to become attached to good parents who will define for him parental love and commitment, and show him his own worth and potential. Such parenting is difficult and should be undertaken only with full knowledge of and willingness to confront the challenges involved.

References
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Cicchetti, D., Toth, S., & Lynch, M. (1995). Bowlby's dream comes full circle: The application of attachment theory to risk and psychopathology. Advances in Clinical Child
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Crittenden, P., & Ainsworth, M. D. S. (1989). Child maltreatment and attachment theory. In D. Cicchetti & V. Carlson (Eds.), Child maltreatment (pp. 432-463). New York: Cambridge University. Greenspan, S. I. (1989). The development of ego. Madison, CT: International Universities Press. Greenspan, S. I., & Lieberman, A. F. (1988). A clinical approach to attachment. In J. Belsky & J. T. Nezworski (Eds.), Clinical implications of attachment (pp. 387-424). Hillsdale, NJ: Lawrence Erlbaum. Hughes, D. (1997). Facilitating developmental attachment. Northvale, NJ: Jason Aronson. Hughes, D. (1998). Building the bonds of attachment. Northvale, NJ: Jason Aronson.
James, B. (1994). Handbook for treatment of attachment-trauma problems in children. New

York: Lexington Books. Karen, R. (1994). Becoming attached. New York: Warner Books. Keck, G., & Kupecky, R. M. (1995). Adopting the hurt child. Colorado Spring, CO: Pinon Press. Levy, D. (1937). Primary affect hunger. American Journal of Psychiatry, 94, 643-652. Levy, T. M., & Orlans, M. (1998). Attachment, trauma, and healing. Washington, DC: CWLA Press. Mahler, M., Pine, R, & Bergman, A. (1975). The psychological birth of the human infant. New York: Basic Books. Provence, S., & Lipton, R. (1962). Infants in institutions. New York: Intemational University Press. Schore, A. N. (1994). Affect regulation and the origin of the self. Hillsdale, NJ: Lawrence Erlbaum. Stem, D. (1985). The interpersonal world ofthe infant. New York: Basic Books.