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Attachment Part Six: Implications of attachment theory: past, present, and future

In parts one through five of our series on attachment, Dr. Goldberg introduced us to attachment theory, described the various patterns, long term outcomes, caregiver and influences influences, and the attachment consequences of adversity. In this sixth and final instalment, Dr. Goldberg discusses the implications of attachment theory for families, public policy, and society in general.

By Susan Goldberg, PhD

Throughout the series we have emphasized the powerful impact of early attachment relationships on infant's lives. We have seen how the various attachment patterns develop and how conditions of adversity influence infant's attachment security and developmental outcomes.  

We conclude the series by considering the impact of attachment theory on children’s lives. How have the ideas and research findings generated by attachment theorists influenced the way children are cared for at home and away from home? Most importantly, has attachment theory helped us better care for our children?   

Bowlby’s World Health Organization report

In 1951, John Bowlby prepared a report on behalf of the World Health Organization (WHO) as a contribution to the United Nations program for the welfare of homeless children. The report would dramatically influence public policy on adoption, social work, and hospital practices worldwide. Over a period of six months, Bowlby gathered data on the impact of maternal deprivation on the lives of homeless or disturbed children. He communicated with social workers and child psychiatrists from across Europe and the United States. Although from diverse backgrounds and largely unaware of each other’s work, Bowlby found their conclusions to be remarkably similar. The same negative outcomes were unanimously reported for children who had been deprived of their mothers.

Bowlby directed his conclusions to governments, social agencies, and the general public, emphasizing the critical importance of the mother-infant relationship. He argued for wide scale policy change and advocated for family support in the form of financial assistance, psychotherapy, and other social services. The WHO report influenced social work practices in many countries. Prior to Bowlby’s ideas, children were typically separated from their mothers with little justification. “Unsatisfactory” home conditions, such as untidiness, poverty, or a mother who was unwed, were sufficient grounds for separating a child from the family home. Bowlby convincingly argued that except for cases of abuse or neglect, a mother’s care was far preferable to separation.  

Since the WHO report, attachment research has reinforced many of Bowlby’s arguments and recommendations. Social support has been shown to buffer the effects of disadvantage and help promote secure attachments in children growing up in adverse conditions.

Hospital policy

Attachment theory also made a significant mark on hospital visitation policies. Present day visiting privileges stand in stark contrast to the policies of the 1950s and early 60s. Visits were discouraged and tightly controlled with parental visits often limited to one hour per week. Minimal visitation rules remained in place despite much opposition and claims that strict visiting limitations were harmful to children.  

As early as 1943, Harry Edelston, a psychiatrist at Leeds, claimed that children were being emotionally scarred by hospital stays. In 1946, Bowlby collaborated with James Robertson, a social worker, to study the effect of hospitalization on infants and young children. They concluded that hospitalized children were often emotionally damaged by their experiences.

But despite this work, many remained unconvinced of the extreme emotional trauma endured by children during hospital stays. In response, Robertson prepared a documentary film depicting a young child’s distressing hospital experience. A Two-Year-Old Goes to Hospital was initially met with outrage from health care professionals; but eventually, hospital policy did change to allow caregivers unlimited visiting rights.  

Institutional care

In part five of the series, we discussed the impact of attachment theory on adoption policy. Many studies were carried out in the 1940s when orphanages were common in North America. Children reared in orphanages were found to be developmentally delayed, displaying unusual social and emotional behaviours. Eventual adoption or foster home placements resulted in improved functioning but for most children many defects persisted.

Bowlby and others interpreted these outcomes as being due to maternal deprivation. Since then, researchers are aware that the privations of institutional care cannot be attributed to maternal deprivation alone but also include the absence of fathers, siblings, and a family context. Nevertheless, Bowlby’s views along with research on orphanages were the catalysts for the demise of institutional care for young children and increasing use of foster care placements. Although a definite improvement over institutionalization, foster care is not always successful. When placements break down and children are repeatedly moved to new foster families, the outcomes are very similar to those seen with institutionalized children.

Attachment and child custody

Attachment theory has an obvious place in the context of child custody disputes. In order to determine the best custody arrangements for a child, a formal custody assessment is required. It is generally accepted that a child’s quality of attachment with each parent should form a central part of the custody evaluation.   But a review of evaluation practices reveals that it is often unclear how attachment is assessed or even what is meant by the term “attachment”.  In many cases there is a misapplication and misunderstanding of attachment theory.  

A report in the February 2005 issue of the Journal of Child Psychology and Psychiatry reveals that child custody assessments often rely on measures that are not supported by research. Further, measures that are empirically based tend to have a limited place in practice. The authors present a rationale for the use of attachment theory concepts and measures in the context of custody determinations. They also make recommendations for developing an attachment-based model of custody evaluation. 

Using attachment theory to improve the child-caregiver relationship

In part five of the series, we looked at how attachment theory has influenced parenting programs and interventions for at risk families. Infant-caregiver therapy has been used successfully with high-risk groups. Modified Interaction Guidance focuses specifically on caregiver behaviours associated with disorganized attachment. A number of studies across Canada are testing the effectiveness of this and other approachs with high-risk families, children with clinical problems, children of adolescent parents, and in families involved with child protection services. Other attachment-based programs have been offered to caregivers of children at risk of developmental delay due to biological, medical, or psychosocial risk. Right from the Start, an 8-week caregiver training course, was designed to improve infant-caregiver interaction to foster attachment security.  Numerous other attachment-based interventions are currently being developed around the world.

Attachment-driven approaches to parenting are applicable not only to high-risk groups but to all caregivers of young infants. Research tells us that the majority of caregivers are unaware of basic attachment principles. Most do not realize that how they respond to their children’s signs of distress has a powerful impact on their infant's long term socio-emotional development. Further, most prenatal education classes do not teach caregivers these principles.   A Simple Gift: Comforting Your Baby is a ten minute videotape designed to explain the principles of attachment theory. It teaches caregivers when and how to respond to their infants’ signs of distress.

Maternal employment and infant care

The impact of daycare on the developing infant-caregiver attachment relationship is the most explosive debates provoked by attachment theory and research. Attachment theory emphasizes the importance of prolonged periods of consistent care for optimal development. What does this say for the over 50 percent of one to three-year-olds in Canada whose mothers work outside the home?  

The evidence

In the 1980s numerous studies looked at the effects of centre-based care on infants. These studies focused on good-quality day care centres attached to academic institutions, with carefully selected staff, low infant-caregiver ratios, and carefully designed programs. No developmental differences were found between infants in day care and those cared for at home by their mothers. In fact, in the case of some disadvantaged infants, day care afforded certain advantages.

But what about the typical experiences of infants in non-parental care? Most parents do not have the luxury of leaving their children in the care of high-quality carefully monitored centres.

In the 1980s, as out-of-home care became more common, an increasing number of studies looked specifically at the effects of maternal employment and a variety of alternate care situations on attachment. These studies found that although the majority of infants were securely attached to their mothers, there was a noticeable decrease in the percentage of secure attachments and an increase in avoidant behaviours.

How do we account for these results given the original findings from the 80s? A major obstacle to measuring the effect of maternal employment on infants is the wide variation in alternate care situations. Children whose mothers work outside the home might be cared for by relatives, family day-care, and day care centres. Further, for each of these situations, wide variations exist in terms of the number of infants in the setting, the ratio of adults to babies, the age and experience of the caregivers, the amount of physical contact, attention, affection, joint activity, and communication that these children experience.

In 1986, Jay Belsky, an attachment researcher at Pennsylvania State University, concluded that using some forms of non-maternal care for more than 20 hours per week in an infant’s first years was detrimental to attachment and development. Belsky’s remarks incited tremendous controversy. Although Belsky’s comments referred to maternal employment and not a specific type of alternate care, the term “day care” figured prominently in the debate. This led many to fear that policy-makers would ignore the earlier studies showing good outcomes with high quality care and to recommend cuts to child-care programs.

In response to the controversy of the 80s, a USA consortium was formed to study the effects of early child care. The National Institute of Child Health and Development Early Child Care Research Network included Belsky and his antagonists. Infant-mother attachment was assessed on 1153 infants from 31 hospitals in nine states using the Strange Situation at 15 months of age. The results revealed no significant effects of any of the alternate child-care variables on attachment to the mother. Infants were more likely to develop secure attachment with their mothers when their mothers were rated as higher in sensitivity and responsiveness regardless of whether they worked at home or outside the home. But child-care experience and maternal behaviour did combine to affect attachment. Specifically, poor quality alternate care, increased hours of care, and changes in care arrangements were associated with insecure attachment when the mother was rated as low in sensitivity and responsiveness to her infant. A smaller but parallel study in Canada in 1999, replicated these findings.

What is the last word on alternate care? Leaving infants in high quality care does not appear to have a negative impact on their development or attachment. Good quality day care includes high staff ratios, well-qualified workers, low turnover, and the assignment of each child to a particular caregiver. Infants n poor quality care have poorer outcomes particularly if their mother is low in sensitivity or responsiveness.

Looking forward

Since Bowlby’s World Health Report of 1951, attachment theory has influenced hospital, adoption, and social-work policies, as well as parenting behaviours. But have we as a society adequately applied what we have learned from attachment theory and research?

Our attitudes and policies on issues that affect children should be informed by our new psychological knowledge. The research demonstrates the importance of early attachment security. The research also shows that caregivers can be helped to develop a better attachment relationship with their children. Our policy decisions regarding infant care should reflect this understanding; however, there is still strong resistance to providing extended parental leave, support for high-quality child care programs, and adequate social assistance for at-risk families.

It is safe to say that we are far from implementing social programs that adequately address infant's attachment needs. But individually as caregivers, we can benefit from the understanding that has arisen from many years of research demonstrating the importance of early attachment relationships for our children’s healthy social and emotional development. 

Diane Benoit, MD, FRCPC

Sheri Madigan, PhD, C.Psych (supervised practice)


Bowlby J. Maternal care and mental health. World Health Organization. 1951:Geneva.

Byrne JG, O’Connor TG, Marvin RS, Whelan WF. Practitioner review: The contribution of attachment theory to child custody assessments. Journal of Child Psychology and Psychiatry. 2005;46(2):115-127.

Karen R. A rage in the nursery: The infant day-care wars. In Karen R. Becoming Attached. New York: Warner Books, Inc. 1994:319-346.

NICHD Early Child Care Research Network. The effects of infant child care on infant-mother attachment security: results of the NICHD study of early child care. Child Development. 1997;68:860-879