Juan Carlos Garelli, M.D., Ph.D.
University of Buenos Aires
Department of Early Development

Hello again Dr Garelli,  

I am currently writing an newspaper article about anxiety in children and why, in this country, we often tend to overlook the chronically anxious child.

I know you are very busy but if you have the time to respond, I would be most interested in your succinct opinion of how anxiety in children develops.  Thank you.

To which I replied:

Anxious children are overlooked because they are seen as overdependent, spoilt, jealous, possessive, greedy, immature and many similar names.

Viewed in the perspective of the Theory of Attachment, children described by clinicians as dependent or overdependent are ones who exhibit attachment behaviour more frequently and more urgently than the clinician thinks proper. Inherent in the terms, therefore, are the norms and values of the observer using them. As you may be aware, this leads to so many difficulties that it renders impossible to explain the child’s behaviour in objective terms.

Overdependency, therefore, is not the term to be used. I prefer to use “Anxious Attachment” in its stead, especially because it enlists our sympathy: it respects the child’s natural desire for a close relationship with an attachment figure, and recognizes that he is apprehensive lest the relationship be ended.

The thesis espoused by the Attachment Theory is that, even though other causal factors may play some part in the development of this condition, those about which by far the most evidence is at present available are experiences that shake a child’s confidence that his attachment figures will be available to him when required.

The main cause of anxious attachment lies in mother’s accessibility to the child’s needs to achieve and maintain an optimal degree of physical and psychological proximity, from birth onwards.

Lack of mother or parent accessibility occurs all too often in an environment of distortion and falsification of the family context which leads to more anxiety and cognitive disturbances.

As Diana Baumrind has repeatedly stated, parents can be categorized as either authoritarian, permissive or authoritative. Authoritarian and permissive parents tend to be inaccessible and give the child a misleading account of what is going on in the family and the reasons for his anxious behaviour. This leads to serious consequences.

In the first place, no child cares to admit that his parent is gravely at fault. To recognize that mother is exploiting you for her own ends, or that father is unjust and tyrannical, or that neither parent ever wanted you or cared for you, is intensely painful. Given any loophole, therefore, most children will seek to see his parents’ behaviour in some more favourable light. This natural bias of children is easy to exploit.

Not only are most children unwilling to see his parents in too bad a light but there are parents who themselves do all in their power to ensure that their child does not do so or at least that he does not communicate an adverse picture to others. This develops a state of mind whereby the child faces a dilemma: is he to accept the picture as he sees it or is he to connive with his parents’ version?

Thus, the data reaching a child from his own experience and from his parents’ view may be regularly and persistently incompatible. to take a real, though by no means extreme, example: a child may experience his mother as unresponsive to him and unloving and he may infer,correctly, that she had never wanted him and never loved him. Yet his mother may insist, season in, season out, that she does love him. Furthermore, if there is friction between them as there inevitably is, she may claim that it stems from his having been born with an ill or contrary temperament. When he seeks her attention, she dubs him unsufferably demanding; when he interrupts her, he is unbearably selfish; when he becomes angry at her neglect, he is held possessed of a bad temper or even an evil spirit. In some way, she claims, he was born bad. Nevertheless, thanks to a good fortune he doesn’t deserve, he has been blessed with a loving mother who, despite all, cares devotedly for him.

In such a situation, as I said above, the child is faced with a most grave dilemma. Is he to accept the picture as he sees it himself? Or is he to accept the one his parent insists is true? to this dilemma there are several possible outcomes. One is that the child adheres to his own viewpoint, even at the risk of breaking with his parent(s), which, as you may easily surmise, increases anxiety, due to fear of loss of attachment figure.

A second and opposite outcome is complete compliance with the parent’s version at the cost of disowning his own. This leads nowhere in terms of decreasing anxiety; on the contrary, the child is constantly trying to placate his attachment figure, and damaging his perception of the world.

A third, and the most common outcome is an uneasy compromise whereby the child tries to give credence to both viewpoints and oscillates uneasily between them.

A fourth outcome is when he desperately tries to integrate the two pictures, an attempt that because they are inherently incompatible is doomed to failure and may lead to cognitive breakdown.

And then this companion piece, written by Arthur Becker-Weidman, an experienced psychotherapist practising in the area of attachment problems:

Attachment is the base upon which emotional health, social relationships, and one’s worldview are built. The ability to trust, and form reciprocal relationships, will affect the emotional health, security, and safety of the child, as well as the child’s development and future inter-personal relationships. The child with disordered attachment may be impulsive, doing whatever the child feels like, with no regard for others. This child may be unable to feel remorse for wrongdoings, mainly because the child is unable to internalize right and wrong. The child may tell you that something is wrong, but that will not stop the child from doing it.

Children, who are adopted after the age of six months or so, may be at risk for attachment problems. Normal attachment develops during the child’s first few years of life. Problems with the mother-child relationship during that time, or breaks in the consistent caregiver-child relationship, prevent attachment from developing normally. There are a wide range of attachment problems that result in varying degrees of emotional disturbance in the child. The severity of attachment disorder seems to result from the number of breaks in the bonding cycle, and the extent of the child’s emotional vulnerability. Emotional vulnerability can be affected by a variety of factors including: genetic factors, pre-natal development including maternal drinking and drug abuse, pre-natal nutrition, and stress, fetal alcohol syndrome and fetal alcohol effect, temperament, birth parent history of mental illness (schizophrenia, manic depressive illness, etc.) One thing is certain; if an infant’s needs are not met consistently, in a loving, nurturing way, attachment will not occur normally.

So how can we tell the difference between a child who “looks” attached, and a child who really is making a healthy, secure attach­ment? This question becomes important for adoptive families, because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone ”mom” or “dad,” snuggles, cuddles, and says ”I love you,” does not mean that the child is attached, or even attaching. Saying, “I love you”, and knowing what that really feels like, can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Normal attachment takes a couple of years of cycling through mutually positive interactions. The child learns that the child is loved, and can love in return. The parent’s give love, and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner, and that the child “belongs” to his family, and they to him. Positive interaction. Trust. Claiming. Reciprocity (the mutual meeting of needs, give and take) these must be consistently present for an extended period of time, for healthy, secure attachment to take place. It is through these elements, that a child learns how to love, and how to accept love.

Older adopted children need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of their new household’s routines, and adapt to living in a new physical environment. Some children have cultural or language hurdles to over­come. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child’s past may start to surface. Some start to get labels like, “manipulative,” “super­ficial,” “sneaky”. Sooner or later the family may decide that this kid is all “take” and no “give”. The child “gives” only when it is to his own benefit. The child can seem to be very selfish and controlling. On the inside, this child is filled with anxiety and fear. The child has not developed the self-esteem that comes with feeling a valued, contri­buting, member of a family. The child cares little about pleasing others, since his relationship with them is quite superficial.

First Year of Life Cycle

The first year is a year of needs. When the infant has a need, it initiates attachment behavior in order to summon a nurturing response from the infant’s attachment figure. The need-gratifying response usually includes touch, eye contact, movement, smiles, and lactose. When gratification occurs, trust is built. This cycle occurs hundreds of times a week, and thousands of times in the first year. From this relationship, a sychronicity develops between parent and child. The caregiver develops a greater awareness of their child and learns just how to respond. The child develops good cause/effect thinking, feels powerful, trusts others, shows exploratory behavior, and develops empathy and a conscience.

When the first year of life cycle undermined, and the needs of the child are not met, mistrust begins to define the perspective of the child and anxious attachment results. The cycle can become undermined or broken for many reasons:

  • Multiple disruptions in caregiving.
  • Post-partum depression.
  • Hospitalization of the child causing separation from the parent and/or unrelieved pain.
  • Parents who are attachment disordered, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relation­ship.
  • Genetic factors.
  • Pervasive developmental disorders.
  • Caregivers whose attachment needs are not met, leading to overload and lack of awareness of the infants needs.

The child naturally develops mistrust and shuts down effective attachment behavior. The developmental stages following the first year continue to be distorted and/or retarded and various symptoms emerge, such as (note this listing is NOT a diagnostic criteria. Diagnoses can only be made by trained and licensed mental health professionals) :

  • Superficially engaging and charming. [phoniness]
  • Lack of eye contact.
  • Indiscriminately affectionate with strangers.
  • Not affectionate on parental terms.
  • Destructive to self, others, and material things.
  • Cruelty to animals.
  • Primary process lying (lying in the face of the obvious*)
  • Low impulse control.
  • Learning lags.
  • Lack of cause/effect thinking.
  • Lack of conscience.
  • Abnormal eating patterns.
  • Poor peer relationships.
  • Preoccupation with fire and/or gore.
  • Persistent nonsense questions and chatter.
  • Inappropriately demanding and clingy.
  • Abnormal speech patterns.
  • Sexually inappropriate.

Parenting

Parenting children with attachment difficulties is a job that requires a great deal of patience, understanding, courage, solid support systems and personal fortitude. Children with attachment difficulties rarely and only superficially return love. Therapists, teachers, child protective services, and even spouses often do not understand the challenge and deception an AD child displays toward an adoptive/foster parent in charge of primary care. Often times the child will project the greatest amount of pathology towards the mother-figure in an attempt to make the world believe that if the mother was not so harsh and controlling, the child would be as lovable as it superficially displays.

Therapists often times are introduced to AD cases witnessing a burned-out parent in their office who is angry, resentful, and full of blame toward their child. Unfortunately the therapist may react by thinking (and sometimes saying) “if this mom would just lighten up on this kid, she would not have so many problems’.” This can lead the therapist to scolding the parent much in the same way the therapist experiences the parent scolding the child. Many well intentioned, but naive, health care workers believe that “all this kid needs is love” and end up creating an alliance with the child against the parents that furthers the family getting the help they desperately need.

Therapy

The basic purpose of attachment therapy is to help the child resolve a dysfunctional attachment. The goal is to help the child bond to the parents and to resolve their fear of loving and being loved. A high percentage of the children that I see are foster or adopted children who have lived in one or more foster homes and have suffered from loss, neglect and/or abuse. Often the children come with a diagnosis of Oppositional Defiant Disorder [ODD] or Conduct Disorder [CD]. Many have a secondary diagnosis of Attention-Deficit Hyperactivity Disorder. The child’s symptoms could also be understood as a Post Traumatic Stress Disorder or Depression stemming from a delayed grief reaction in response to one or more significant losses early in childhood. Whatever the diagnosis is, it is important that the developmental history receives the consideration required to provide the appropriate treatment. Dyadic Developmental Psychotherapy is an evidence-based treatment that is effective for treatment of Reactive Attachment Disorder and Complex Trauma. There have been two empirical studies published in professional peer-reviewed journals regarding the efficacy of this treatment.

Because attachment is developed in the first years of life, often times the trauma driving the child’s pathology is pre-verbal. The child needs a solid educational component of treatment for the child to understand what force is driving the feelings and controlling the child’s behavior. The parents also need the education and understanding that the child’s behavior is not caused from their parenting, but from past traumas. From this base then, new parenting interventions can be designed from a cooperative relationship to fit a child with special needs.

A major dynamic in the treatment, is the affective work needed to heal the emotional wounds that drives these children’s behavior. A corrective emotional experience is orchestrated allowing the child to express these feelings, recognize and recall them and identify the events and the people involved. In essence, the child going through this experience with their parents allows for resolution of old pathological emotions while simultaneously creating powerful new bonds. As with any good trauma therapy, revisiting the trauma in order to integrate the fragmented and overwhelming experiences is crucial for healing. The revisiting must be done in a sensitive and titrated manner to avoid dysregulating the client.

©Copyright 2008 by Arthur Becker-Weidman, Ph.D.. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org.

 From Wikipedia

Secure Attachment: Securely attached people tend to agree with the following statements: “It is relatively easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don’t worry about being alone or having others not accept me.”

Anxious-Preoccupied Attachment: People who are anxious or preoccupied with attachment tend to agree with the following statements: “I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them.” People with this style of attachment seek high levels of intimacy, approval, and responsiveness from their partners. They sometimes value intimacy to such an extent that they become overly dependent on their partners—a condition colloquially termed clinginess. Compared to securely attached people, people who are anxious or preoccupied with attachment tend to have less positive views about themselves. They often doubt their worth as a partner and blame themselves for their partners’ lack of responsiveness. They also have less positive views about their partners because they do not trust in people’s good intentions. People who are anxious or preoccupied with attachment may experience high levels of emotional expressiveness, worry, and impulsiveness in their relationships.

Dismissive-Avoidant Attachment: People with a dismissive style of avoidant attachment tend to agree with these statements: “I am comfortable without close emotional relationships. It is very important to me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me.” People with this attachment style desire a high level of independence. …Some may even view close relationships as relatively unimportant. Not surprisingly, they seek less intimacy with relationship partners, whom they often view less positively than they view themselves.

Fearful-Avoidant Attachment: People with a fearful style of avoidant attachment tend to agree with the following statements: “I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I sometimes worry that I will be hurt if I allow myself to become too close to others.”

…secure attachment styles are by no means a guarantee of long-lasting relationships.

Nor are secure attachment styles the only attachment styles associated with stable relationships. People with anxious-preoccupied attachment styles often find themselves in long-lasting, but unhappy, relationships. Anxious-preoccupied attachment styles often involve anxiety about being abandoned and doubts about one’s worth as a relationship partner. These kinds of feelings and thoughts may lead people to stay in unhappy relationships.

…Differences in attachment styles influence both the frequency and the pattern of jealous expressions. People who have anxious-preoccupied or fearful-avoidant attachment styles experience jealousy more often and view rivals as more threatening than people who have secure attachment styles. People with different attachment styles also express jealousy in different ways. One study found that:

“Securely attached participants felt anger more intensely than other emotions and were relatively more likely than other participants to express it, especially toward their partner. And although anxious participants felt anger relatively intensely, and were as likely as others to express it through irritability, they were relatively unlikely to actually confront their partner. This might be attributable to feelings of inferiority and fear, which were especially characteristic of the anxiously attached and which might be expected to inhibit direct expressions of anger.”

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