How to Effectively Use Bonding Evaluations

1. How to Effectively UseBonding Evaluations Christine A. Darsney, Ph.D. Children and the Law Program MGH Law & Psychiatry Service Instructor of Psychology, Harvard Medical School

2. Objectives and Agenda • Background information on attachment theory and bonding. • Overview of guidance that has been provided on bonding evaluations for mental health professionals. • Thoughts about the limitations of these evaluations as they are currently being conducted. • Discussion and questions.

3. For Later Discussion • Assertion by a mental health professional that a six month old infant who has been in a foster home for two months would suffer severe adverse disruption of attachment if returned to the biological parent. • Assertion by a mental health professional that an 18 month old child who is showing severe distress prior to, and after, visitation with a biological parent, when the child has been in a stable foster home placement for one year, is reflective of attachment issues and hence, the child should not be removed from the care of the foster parent.

4. For Later Discussion • Assertion by a mental health professional that interviewing a 6 year old child in the foster home (where the child has lived for more than one year) results in no adverse influence of the foster parent on the child’s report. • Assertion by a mental health professional that the same 6 year old child, who is protesting leaving the foster home to attend visits with the biological parent, and then displays great upset when returned to the foster home, should not be removed from the care of the foster parent due to concerns about attachment.

5. Bonding or Attachment? “The terms ‘attachment’ and ‘bonding’ are used to define two separate phenomena by some and used interchangeably by others. Attachment is a strong emotional connectedness between children and their primary caretaker(s) that endures over space and time, and is necessary for physical survival and emotional well-being. Bonding, on the other hand, has historically been portrayed as an almost mystical experience for mothers with their newborn baby that is thought to lead to stronger, long-term attachment.” (Barone, Weitz, & Witt, 2005, p. 397)

6. Attachment Theory

7. John Bowlby and Attachment Theory • Working in a home for maladjusted boys, Bowlby became convinced that early disruptions in the mother-child relationships had led to later psychopathology (1930s). • Bowlby was influenced by the work of Konrad Lorenz (1935) indicating that infant geese became imprinted, during a critical window of development, on “parents” (even those who did not feed them). • Bowlby was also influenced by the work of Harry Harlow in the 1950s, who observed that infant rhesus monkeys, when stressed, preferred a terry cloth covered “mother” over the wire mesh “mother” that provided food.

8. John Bowlby and Attachment Theory • Bowlby viewed infants as born with a drive for attachment, as displayed through an attachment behavioral system, which served an evolutionary purpose of safety—infants who stayed close to their mother were less likely to be killed by predators (use of the mother as a “safe haven”). • He noted that observations of children separated from mothers followed a predictable pattern—intense distress, angry protest, and then despair—even if cared for by others.

9. John Bowlby and Attachment Theory • Attachment Behavioral System is activated by danger or stress: • Conditions of the infant—illness, fatigue, hunger, pain • Conditions of the environment—threats, distance from the mother. • Attachment behaviors displayed by an infant (dependent upon age/developmental level: • Crying (to draw the mother in) • Visual tracking of the mother • Reaching for the mother • Moving toward/following the mother

10. John Bowlby and Attachment Theory • Bowlby talked about an “attachment bond” as an affectional tie that one individual has for another who is perceived as stronger and wiser (an infant would have an attachment bond toward the mother). • Hallmarks of an attachment bond: • Persistent across time • Involves a specific person (not interchangeable) • Emotionally significant relationship • There is a wish to remain in close proximity to the person • Distress is felt at involuntary separation from the person • In times of distress, the individual seeks security and comfort from the person

11. John Bowlby and Attachment Theory Bowlby noted that a parent should feel a parental bond toward to a child, not an attachment bond as, if the parent seeks security and comfort from a child, it is a sign of pathology in the parent, and a cause of pathology for the child. (Cassidy, 2016, pp 12-13)

12. John Bowlby and Attachment Theory • Bowlby stressed that an infant has multiple attachments, in that there are multiple individuals to whom the infant directs attachment behavior: • Parents • Older siblings • Grandparents • Other members of the extended family • Other consistent caregivers (day care providers)

13. John Bowlby and Attachment Theory • Infants are thought to build an attachment hierarchy: • With a principal attachment figure • In the absence of the principal attachment figure, the infant will seek comfort and security from others in their hierarchy • The hierarchy is built partly depending upon: • Time spent in each person’s care • Quality of care provided

14. Why Do We Care about Attachment? • Bowlby’s research with British war orphans indicated that when infants are raised in institutional care without stable and continuous caregiver relationships, they suffer deficits in cognitive, emotional and social development (as was also seen with Harlow’s infant rhesus monkeys and, more recently, with Romanian orphans). • Attachment relationships are needed for normal cognitive, emotional and social development: • Regulation of emotional states, behavioral control. • Mental representations (internal working models) of relationships across the lifespan are rooted in early attachment relationships.

15. Mary Salter Ainsworth & Attachment Security • Part of Bowlby’s research team. • Research in Uganda in the 1950s. • Research in Baltimore in the 1960s and 1970s. • Use of home observations and the Strange Situation: • Infants/toddlers age 12 to 20 months. • Caregiver and infant in a playroom with intermittent periods of the stranger coming and going, and the caregiver coming and going. • Child observed for signs of distress, attachment, and exploratory behavior.

16. Mary Salter Ainsworth & Attachment Security • On the basis of the Strange Situation, infants were classified accordingly to attachment security: • Securely attached (70%) • Insecure-avoidant (15%) • Insecure-resistant (ambivalent) (15%)

17. Mary Salter Ainsworth & Attachment Security • Securely attached children: • Appeared confident that their mother would meet their needs. • Used the mother as a “safe base” to explore the room. • Sought the mother when distressed. • Were easily soothed by the mother when distressed. The secure attachment was thought to arise from sensitive caregiving—the parent is attuned to the infant’s signals and responds appropriately to the infant’s needs.

18. Mary Salter Ainsworth & Attachment Security • Insecure-avoidant children: • Were very independent of the mother. • Did not reference the mother while exploring the room. • Showed no sign of distress when the mother left the room. • Played normally with the stranger in the room—no distress. • Showed little interest in the mother upon her return. • The mother and the stranger were equally able to comfort the infant. The insecure-avoidant attachment was thought to arise from insensitive and rejecting caregiving, and a tendency to be unavailable in times of distress. The child has no expectation that needs will be met.

19. Mary Salter Ainsworth & Attachment Security • Insecure-resistant (ambivalent) children: • Explored the room less and cried more. • Displayed intense distress when the mother left. • Avoided the stranger—showed distress/fear of the stranger. • Upon the mother’s return, approached the mother but resisted contacted (i.e., pushed the mother away). • Showed clingy behavior, but rejected the caregiver when the caregiver attempted interaction or attempted to soothe. The insecure-ambivalent attachment was thought to arise from an inconsistent response from the caregiver to their needs—sometimes their needs are met, sometimes they are not.

20. Main and Solomon (1990) • Disorganized attachment: • Insecure attachment • Show disruption, not a smooth flow of behavior—freezing, confusion, disorientation • Lack a coherent attachment strategy, but may show pieces of the other attachment styles • Higher percentage seen in high risk samples (as cited by Solomon & George, 2016)

21. Strange Situation Procedure • Was meant for RESEARCH only! With children age 12 to 20 months. • This is not a procedure that would be used clinically. • It is not a procedure that would be used in a bonding evaluation. • Ainsworth acknowledged that after 20 months, it was not clear what the child’s behavior would indicate. Attachment behavior becomes more complicated, and more difficult to assess, especially after age 3.

22. Important Points about Attachment Theory • Focus on the first 18 months of life, with a particular focus on 6 months to 15 months (when infants are more wary around strange adults). • Bowlby felt that an infant’s readiness to become attached continues throughout the first year of life. • But, attachment security can change over time, and research suggests that infants can establish new attachments after the first year of life.

23. What About Adoption and Foster Care? • Studies in the 1970s suggested that children adopted after the beginning of the attachment process (ages 6 to 8 months) had difficulty forming positive attachment relationships with adoptive parents. • More recent research, however, suggests that children adopted during the first year of life show similar attachment formation to adoptive parents as those who remain with biological parents. (Howes & Spieker, 2016, p. 317)

24. What About Adoption and Foster Care? Dozier & Rutter (2016): • Children placed into care before 1 year of age begin to organize attachment behavior around a foster parent “quickly.” • Children who are more than approximately 1 year of age tend to show difficulty trusting new caregivers but also tend to be able to establish attachment relationships depending upon the sensitivity of the adults involved.

25. What About Adoption and Foster Care? Dozier & Rutter (2016): • Attachment formation is relationship-specific. • “. . . children who have experienced early adversity are especially in need of nurturing care. Without such care, they do not appear to be able to organize their attachment relationships.” (p. 704).

26. What about Adoption and Foster Care? • Discontinuous care is a risk factor for insecure attachment. • Institutional care is a significant risk factor for infants (indiscriminate attachment/disinhibited attachment/attachment disorder). • More sensitive previous and current caregiving is linked to more security in attachment. • Overall warmth, sensitivity, and attunement to the child’s overtures and needs results in more secure attachment.

27. What About Adoption and Foster Care? • It should not be assumed that all children who are removed from the care of parents in the context of abuse and neglect are insecurely attached. • But children who have been directly abused by caregivers are often caught in the paradox of being fearful of the very person they would turn to for protection and support (disorganized attachment—freezing when reunited in the Strange Situation). • Which may limit their ability to form a trusting relationship with a caregiver.

28. What About Adoption and Foster Care? Child vulnerabilities and risks are additive in determining resilience: • Temperament • Prenatal exposure to substances • Developmental issues • Medical risk factors • Children with these areas of concern merit additional consideration when considering attachment

29. BONDING EVALUATIONS

30. Barone, Weitz & Witt (2005): Psychological bonding evaluations in TPR cases. • Note that evaluations in the context of TPR cases should focus on both parental fitness and the child’s attachment. • These areas are inextricably linked—parents with impaired fitness are also likely to cause impaired attachment. • “As such, the purpose is to offer long-term predictions about potential effects. . . and to make recommendations that will avoid, or at least mitigate, lifelong psychological trauma for that child.” (p. 389).

31. Barone, Weitz & Witt (2005): Psychological bonding evaluations in TPR cases. • “Bonding” should be a particular focus under certain circumstances: • Prolonged foster care placement • Strong attachment between child and foster parent • Lack of contact between child and biological parent • Special needs of the child that increase vulnerability if removed from an attachment figure

32. Barone, Weitz & Witt (2005): Psychological bonding evaluations in TPR cases. • The authors argue that attachment should always be considered in evaluations for TPR cases, and that both parenting capacity and attachment should be considered together. • They propose a model where attachment is considered both with regard to the parent and the foster parent in the same evaluation (citing a similar model proposed by Dyer in 1998).

33. Dyer (1999): Psychological Consultation in Parental Rights Cases “A bonding evaluation is a specialized type of assessment whose goal is to determine the nature of the child’s attachment to birth parents and foster parents, especially to address the question of who occupies the position of greatest centrality in the child’s emotional life.” (p. 112).

34. Components of a Bonding Evaluation (Barone et al., 2005) • Review of case history/background information. • Interviews of the relevant parents and caregivers to consider their perception of their relationship with the child, and understanding of the child’s personality, needs, strengths/weaknesses, likes/dislikes, interests/activities, etc. • Observation of the child with the parent/caregiver for approximately 45 minutes. • Interview of the child (depending upon age).

35. Components of a Bonding Evaluation (Barone et al., 2005) • Behaviors to note in the observation in order to assess bonding: • Does the child appear comfortable with the parent/caregiver (i.e., animated, verbal child versus anxious and avoidant)? • Does the child seek comfort and guidance from the parent/caregiver? • Do the parent/caregiver and child initiate interactions with each other? How does the parent/caregiver engage a reticent child?

36. Components of a Bonding Evaluation (Barone et al., 2005) • What does the interaction look like? • Does the child explore the room with the parent/caregiver there? • Does the parent/caregiver respond to a child’s overtures? • Does the parent/caregiver respond to the child’s verbalizations? • Do they play together or does the parent/caregiver just watch the child? • Do they sit close together? Is there touching?

37. Components of a Bonding Evaluation (Barone et al., 2005) • What does the interaction look like? • Do the parent/caregiver and child smile at each other? Do they make eye contact? • Does the child become upset if a brief separation occurs? • How easy is it for the child to make his/her needs known to the parent/caregiver? How perceptive is the parent/caregiver ofthe child’s signals? Does the parent/caregiver anticipate the child’s needs? • Does the child focus on the evaluator for help, guidance, or interaction, even with the parent/caregiver in the room?

38. Components of a Bonding Evaluation (Barone et al., 2005) • Evidence of attachment between a child and a parent is seen in a range of behavior, depending upon the child’s age. • Infancy: • The infant tracks the caregiver visually. • The infant appears alert and interested. • The infant can be comforted by the caregiver when distressed.

39. Components of a Bonding Evaluation (Barone et al., 2005) • Ages 1 to 5 years: • The child will explore the environment, using the parent/caregiver as a safe haven. • The child will respond positively to the parent/caregiver. • The child will display reciprocal interaction with the parent/caregiver. • The child may display distress about a brief separation and display pleasure about the parent/caregiver’s return.

40. Components of a Bonding Evaluation (Barone et al., 2005) • School-aged: • The child engages in conversation with the parent/caregiver and makes eye contact. • The child may seek physical contact or remain in close proximity with the parent/caregiver. • The child reacts positively to the parent being in close proximity to him/her. • The child shares information about school, activities, their overall life with the parent/caregiver.

41. Components of a Bonding Evaluation (Barone et al., 2005) • Adolescent: • Active engagement with the parent. • Display some awareness and acceptance of a parent’s values. • Display some acceptance of limits offered by the parent.

42. Components of a Bonding Evaluation (Barone et al., 2005) The authors note that bonding is a two-way street. It is not just about the child’s attachment to the parent/caregiver. It is also about the parent/caregivers’ attachment to the child. How interested is the parent/caregiver in the child’s daily life, activities, personality, areas of difficulty? How invested is the parent/caregiver in meeting the child’s needs?

43. Components of a Bonding Evaluation (Barone et al., 2005) • The authors also note that there should be some consideration in the evaluation of the potential emotional harm that a child could suffer if a decision is made to break a bond/attachment to a parent or caregiver. Such consideration should include: • Consideration of the quality of care/ability to meet the child’s needs. • Consideration of the ability to help the child cope with loss, and allow the child to grieve/accept that the child loved the lost caretaker. • How will contact with the previous caretaker be managed, if allowed? • Will there be support for therapeutic services to help the child with the loss?

44. Budd, Connell and Clark (2011). Evaluation of Parenting Capacity in Child Protection. • Offer very little commentary except for two pages on “Issues in Conducting Bonding or Attachment Assessments.” (p. 109) • The authors repeatedly emphasize that there are no validated tools or protocols for assessing attachment in the context of these evaluations. • Clearly not fans of the idea: “Beware! Bonding assessments are difficult to conduct, as there are no validated measures for assessing attachment in the foster care environment.” (p. 110).

45. Budd, Connell and Clark (2011). Evaluation of Parenting Capacity in Child Protection. “Given the absence of empirical support for bonding or attachment assessment in a child protection context, it may be helpful to reframe the question to focus on the psycholegal issues. These questions could include how the child’s removal from the foster parents may affect the child, the strengths and limitations of the child’s parents, and positive and negative factors associated with return to the child’s parents.” (p. 110)

46. Budd, Connell and Clark (2011). Evaluation of Parenting Capacity in Child Protection. • Potential positive factors associated with a return to the biological parents include: • Sense of belonging. • Need to know the biological parent loves the child. • Being part of an extended family network. • Cultural factors that may be important then or in the future.

47. Budd, Connell and Clark (2011). Evaluation of Parenting Capacity in Child Protection. The authors note that there are many factors in these cases that are beyond the expertise of mental health professionals including: “. . . moral and values questions regarding parental rights, empirical data regarding stability of foster home placements, viability of long-term foster placement as contrasted to adoption, and the inherent unfairness of comparing what a foster family might be able to provide compared to the biological parent in the way of opportunities.” (p. 111)

48. Arredondo & Edwards (2000). Attachment, bonding, and reciprocal connectedness. • California Center for Families, Children and the Courts. • The authors stress the limitations of attachment theory, especially as they pertain to court matters. • The authors argue that “attachment” is too narrow a concept because of its inherent focus on security-seeking on the part of the child.

49. Arredondo & Edwards (2000). Attachment, bonding, and reciprocal connectedness. They offer a new concept, reciprocal connectedness, “as more suitable for judicial use because it comprises both the processes of bonding and attachment and the broader spectrum of human interactions necessary for normal brain and social development. Its use will enable judges to assess more accurately the true condition of parent-child relationships and, thus, to make better decisions.” (pp. 109-110)

50. Arredondo & Edwards (2000). Attachment, bonding, and reciprocal connectedness. “Modern attachment theory addresses the dyadic nature of relationships, but excludes the wider system of relatedness in which most children participate. It draws on historical and experimental psychological theory as its basis. Forensic mental health professionals, however, have extended the concept of attachment beyond its scientific and theoretical basis. When testifying about attachment, experts may thus inadvertently give the false impression that their subjective clinical impressions possess scientific validity. For example, the authors have heard experts declare that because a child was bonded to her foster mother, she could not be bonded to her biological mother.” (p. 110).