1st National Conference on the Mental Health Aspects of Persons Affected by
Held at Liverpool Hospital
ATTACHMENT, FAMILY SEPARATION AND MENTAL HEALTH: MAKING CONNECTIONS by Timothy Keogh
Department of Medicine, University of Sydney Australia
The aim of this paper is to discuss the relevance of attachment theory to the needs of people who are in care or who
have experienced care as a result of family separation or loss. Whilst the significant emotional and psychological consequences
of family separation for relinquishing mothers and families are acknowledged, the focus of the paper concerns the mental health
aspects of those placed in various forms of care following separation or loss. The paper will review some of the links between
family separation, which results in adoption, foster care, and institutionalized care and their mental health outcomes and
attempt to demonstrate how attachment theory can assist in understanding these outcomes.
The paper will discuss some preliminary data concerning associations between disruptive experiences in the backgrounds
of adult offenders in the New South
Wales prison system and their
mental health and recidivism.
Respect and consideration of those who have spent time in care and those who have relinquished children is implicit
in the material to be presented along with an awareness that some of the material may be painful for those who have had such
There have been a variety of studies, which have demonstrated how disruptions to attachment and bonding can adversely
impact on emotional and psychological development (Fonagy, 2001; Morton & Frith, 1995; Sperling & Bermann, 1994). Family separation and loss experiences have been clearly identified as a risk factor
for the development of mental health problems in childhood and adulthood (Fraser, 1997).
Although biology, temperament and experiences all play important roles, children who have had interrupted relationships
with primary caregivers are more likely to have compromised mental health. (Folman, 1996).
Separation and loss can be traumatic and its impact depends on the circumstances of the separation or loss (Keogh,
1998). The work of Van der Kolk (1996)
and others (Glaser, 1998) has shown how the timing and impact of trauma can lead to additional and sometimes devastating psychological
and biological consequences. Examples of traumatic family separation are revealed
in the disturbing accounts of survivors of the Stolen Generation.
In the case of family separation or permanent loss resulting in care placement, the child’s age, the number of
placements, the chronicity of the separation and the trauma associated with it have all been shown to significantly determine
the mental health impact of the original separation or loss experience.
A WHO expert committee (1997) set up to review issues concerning child mental health and psychological development
noted that the continuity of relationship to parent figures is especially important in the first few years of life. They also
indicated that children are most at risk when they experience multiple changes of parent figures or when they are reared in
institutions with many attendants who have no special responsibility for individual children.
They concluded that there are significant dangers to the emotional and psychological well-being of children who are
delayed in their adoption process, to children who are taken in and out of institutions and foster care, or to those who are
left to experience an impersonal institutional upbringing.
Further, there is now a large literature, which has documented the particular vulnerability of infants to the stress
associated with separation, loss or insufficient care in their first years of life.
Glaser (1996) has summarized a considerable amount of this research, which demonstrates the potentially traumatic effect
of such experiences on the growth of the brain. Damage to the brain from such
experiences not only compromises brain development itself, but such compromised brain functioning can also interact with later
adverse developmental experiences adding to their negative impact and predict a greater likelihood of poor mental health adjustment
in a later life.
Society is still coming to grips with the reality that separation and loss experiences, which when compounded by poor
subsequent attachment opportunities, can severely compromise a child’s future.
The adverse effects of institutionalisation on mental health have been identified for some time (Spitz & Wolf,
1945) along with evidence, that there are differential mental health effects associated with institutional care, foster care
and adoption (REF**).
There has documented a litany of the adverse effects of institutionalisation which have included increased susceptibility
to infectious morbidity, poor nutrition and growth and retarded cognitive development.
The risk of physical and sexual abuse is such settings has also become painfully clear (REF**).
There are also numerous accounts of the sexual and other abuses that institutionalized children have experienced which
would have compounded their already adverse developmental milieu (REFS**). Sequelae
of sexual abuse include specific mental health difficulties which are related to the extent and nature of the abuse can encompass
severe psychopathology including dissociative states and borderline personality disorder (REFS**). Frank et al (1996) recently noted that it significantly increases
the likelihood of that children will grow up psychiatrically and emotionally impaired.
Goldfarb (1946) following on from the studies of Spitz and Woolfe (1945) demonstrated that there were five symptom
clusters of psychological problems that persisted in institutionalized children into adolescence. These were: hyperactivity and disorganization, indiscriminate demands for affection and attention, superficiality
of relationships, the absence of normal anxiety in reaction to failure or rebuke and social regression.
Subsequently, Tizard et al (1975) followed the emotional and behavioural development of 40 children who were place
in care. They noted a number of features of such children, which indicated impaired
capacity for attachment manifested in their inability to turn to peers for emotional support, and to achieve friendship. They concluded that compared to children who were adopted or returned to impoverished
families that the institutionalized children were ten times more likely to develop such problems. Rutter and Quinn(***) also replicated such findings with a
cohort of young women and showed that although later positive experiences might moderate some of the earlier adverse ones,
compared to a control group institutionalized girls as women were much more likely to have serious emotional adjustment problems
which interfered with their capacity for emotional well-being.
Foster care and adoption
Mental health sequale have also been associated with foster care or adoption (Ref**).
Adoption per se cannot be said to contribute to poor metal health outcome because it may also represent a protective
factor by which children can build up resilience to mental health problems. This
is an important caveat in relation to foster care and adoption and their impact on mental health. This relates to research which has shown that resilience to mental health problems can build up if a child
has available to them a constant and consistent alternative attachment which such experiences often provide.
Indeed, Valiant (REF**) argued that the best single predictor for a long term positive mental health outcome in such
children is the chance to form on good relationship with someone, not necessarily a parent or a relative.
Positive re-attachment opportunities are therefore pivotal in increasing the potential for better mental health outcomes. Also the child’s age, delays in fostering, the number of foster placements and
matching of the child’s development needs with a suitable foster parent have proven to be especially predictive of better
mental health outcome (REFS**).
In the U.S. however, children are currently entering foster care at increasingly earlier ages, when as previously noted,
they may be at most risk to adverse impact on their brain development which combined with
bonding and attachment disruptions can have profound implications for their future mental health (REFS***).
The American Academy of Child and Adolescent Psychiatry (REF**) in a report on foster care has noted that fostered
children commonly blame themselves and experience guilt about removal from their parents. They also note that such children
often want to return the parents even if they were abused by them, and feel unwanted if they have to wait for a long time
for a foster parent. Such children also have mixed emotions about attaching to
foster parents and have feelings of insecurity and uncertainties about their future.
Many of these experiences become the themes in their adult psycic life. Such
children as adults often experience feelings of aloneness and unworthiness that are deeply felt and can interfere with taking
advantage of everyday opportunities for happiness that many other people take for granted.
As a group they are at risk for later depression, substance abuse, and criminality and can have relationship difficulties
associated with the various forms of insecure attachment (Miller et al 2000)
Being aware of the difference of a child’s sense of time and taking into account the age and developmental needs
of a child or infant are crucial determinants in facilitating their adjustments to the stresses associated with being fostered
As a group adopted children appear to have more mental health problems than non-adopted children. There a variety of factors, which impact on this outcome including the experiences prior to adoption, delays
in the adoption process, and the quality of the attachments, made to adoptive parent(s).
Notwithstanding this Miller et al (1996) were able to replicate a study conducted by Warren (1994) which demonstrated that adopted adolescents were more likely to receive mental health services
that non adopted adolescents. These findings corroborate the findings of a meta analyses of data concerning a variety of psychological
and behavioral outcomes by Wierzbicki (1993) who showed adopted children showed consistent negative differences on all measures
compared to non adopted children. Slapp, Huang and Goodman (2001) have also demonstrated
that adoption is a risk factor for attempted suicide during adolescence. They
found that compared to non-adopted children they were more likely to have depressive symptoms, have a poor self-image, be
involved in more risk taking behaviors and have less of a sense of connectedness in their significant relationships.
Distilling many of the above-mentioned findings concerning the mental health sequalae of family separation it becomes
clear that disruptions to attachment are of key to the resultant mental health outcomes.
An understanding of attachment research and theory therefore appears helpful in understanding the processeswhich appear
to underpin these outcomes.
The fact that relationship or attachment with caregivers
centrally involved in a child’s upbringing mediate development is a concept central to early intervention strategies
and to the risk and resilience literature (Fraser 1997). This literature has identified categories of factors, which can either
influence, the development of maladaptive behaviours or afford some protection against them.
Attachment Theory (Fonagy 2001) in particular posits that secure attachment with caregivers fundamentally
mediates psychological adjustment. Bowlby (1958) had suggested that security
and relatedly attachment were prime motivators in humans and saw secure attachment as an important precursor to stable adult
Bowlby (1958) can be credited for having been the first theorist and clinician to articulate the
importance of attachment to the understanding of human behaviour. He believed
that babies and infants had an evolutionary related need to ensure their safety by establishing proximity to with significant
adults in their environment (usually their parents).
Bowlby specifically believed that children make internalized representations of these of the basic
style of the relationships with their parents and that these internal working models become a template, which guides
their relationships with others. He suggested that these models are built up around a relatively small and simplistic set
of abstractions from these experiences. These interpersonal transactions consolidate
into internal working models during the period 9 - 18 months of age. This is also that time during which ‘object permanence’
(i.e. a stable psychological representation of another person) crystallises in the infant (Piaget 1954).
The development of Bowlby’s thinking resulted from a series of studies undertaken at the Tavistock
Clinic in London in which a large number of babies’ reactions were observed where
their contact with their primary caregivers was subject to interference and separations. (Bowbly 1971).
Ainsworth and her colleagues (1987) subsequently developed a methodology to explore these findings. She developed a technique that became known as the 'strange situation' experiment
in which a child was brought into the strange situation of a social laboratory and exposed to a graded series of mild disturbances
to their contact with caregivers and culminating the caregivers brief departure.
They studied a large number of mother infant dyads and developed a typology of children’s’ attachment styles. The typology described children as being either securely, avoidantly
or ambivalently attached. Subsequently a disorganized category of attachment
style was added (Main and Hess 1990).
In the majority of cases she observed that children would react in a way that suggested that they
could be characterized as ‘secure’. These children manifested distress
when the parent left but was relieved when the parent returned. They demonstrated
more concentration when they are at play, and had greater social competence. They
also displayed more positive affect and had greater ego resilience.
In contrast the ‘avoidant’ attachment style was characterized by distress during the
separation from caregivers and by a lack of acknowledgment or rejection during the reunion phase. The ‘ambivalent’ style was characterized by high level of distress during the separation and
by a mixed approach and rejection during the reunion.
With the ‘disorganised’ attachment style during reunion with their caregiver, these
infants exhibited disorganized and contradictory behaviour. This included approaching
the caregiver with the head averted, falling to the floor on approach to the caregiver and a kind of frozen response whereby
they seem stuck to the floor and unable to approach the caregiver. This attachment
style is often more directly the consequence of abuse experiences of various kinds. The internal representations of these
children are chaotically organized and often feature violent images (Main & Cassidy, 1988). It is therefore not surprising that this category has been shown to predict the development of aggressive
The common underpinning issue in all these insecure attachment styles is that the basic anxiety
is related to a feared loss of the (object) parent. Such experience according
to Bowlby (1971) was primarily mediated by the caregiver’s capacity for empathy or empathic attunement as Stern (1985)
has referred it to.
Crittenden (1996) has developed further sub-categories
to this basic typology using the dimensions of cognition and affect. She saw
that the attachments in a child’s life is the 'scaffolding’ which allows the mind to interact with reality.
Zeanah, Bakshi, Boris and Lieberman (2000), and Zeanah Boris and Lieberman (2000) have also extended categories of
attachment in infants and articulated secure base distortions that include categories of disordered attachment with: 1. Self-Endangerment,
2. Inhibition and 3. hypervigilance.
Also pertinent is a schema of adult attachment styles developed by Bartholomew (1990), which built
on the work of Hazan and Shaver (1987) who had proposed three categories of adult attachment roughly paralleling Ainsworth’s
(1987) childhood categories. They proposed ‘secure’, ‘ambivalent’
and ‘avoidant’ categories of attachment in adults.
Bartholomew’s schema proposes four categories of attachment in adults as can be seen in diagram
A Four Group Model of Adult Attachment (Bartholomew
Model of Self (Dependence)
Model of Other (avoidance)
Bartholomew described four broad types of adult attachment
1. Firstly, a secure autonomous attachment style, which is associated
with an expectation of relationship permanence and a positive view about oneself and others. Such individuals do not generally
worry about being alone or have worries about being accepted by others
2. Secondly, a dismissing attachment style in which the individual is
comfortable without close emotional relationships but where it is important for the individual to that they are not dependent
on others. It is other s who are viewed negatively rather than the self.
3. Thirdly, a preoccupied style which is characterised by an anxious and
ambivalent approach to others. Individuals with this attachment style experience
others as reluctant to get close and worry about their self worth.
4. Finally, a
fearful style which is charcterised by mistrust of others and a worry about getting hurt if others are allowed to get close.
West and Keller (1994) have noted that the defensive attachment patterns results in defensive styles
that represent unresolved mourning of the longed for but never experienced a tender care giving relationship with usually
the parent. They claim that such unresolved feelings always result in the renunciation
of authentic relatedness with others in favour of a detachment from their attachment emotions, which cause them to adopt one
of a number of defensive styles.
In the last ten to fifteen years there has also been significant progress in linking attachment to the development
of psychopathology (del Carmen and Huffman 1996; Boris, Wheeler, Heller and Zeanah 2000). Substantial progress has also been
made linking insecure attachment and depression (e.g. Cummings and Cicchetti 1990; Lyons-Ruth 1996).
Gender differences have also been demonstrated with males manifesting risks of criminality violence substance abuse
and occupational instability whilst women with the a sequalae of insecure attachment are more likely to feature depression,
suicidal behavior, multiple somatic complaints, substance abuse and sometimes become involved in prostitution REF**). Not surprisingly the care of children of insecurely attached parents can be compromised.
Fonagy (1997) has argued that disruption to attachment leads to a failure to mentalize about experience and that this
lack of a self reflectively ability results in a need to deal with psychological distress physically. This is similar to Freud’s (1918) original idea of motor discharge in the absence of mature defences. From this perspective aggression can be seen as a defence to safeguard the self from
fantasies and thoughts which the self is not able to protect itself through mental manipulation (Fonagy & Target 1995).
Along with findings of the temporal stability of insecure attachment and its relationship to mental health these findings
shed light on the ‘why’ of family separation and loss. That is, what
it is about family separation and loss, that links it to adverse mental health outcome
The development of conduct problems and criminality and its links to attachment is currently a burgeoning area of research. Kosky (1992) for example has showed juvenile offenders to have high rates of psychological
morbidity and mental health. Adult offenders also as have high rates of mental
health problems (REFS**). These offenders often have high rates of care experiences
in there backgrounds suggesting that such experiences link to their mental health outcomes which encompass deficits which
directly link to their propensity to offend (Keogh, 2000).
For example Rosentein and Horowitz (1996) have shown that adolescents with a ‘dismissive’ attachment style
rely on an attachment strategy that minimizes distressing thoughts and affects associated with rejection by the attachment
figure. They specifically found that adolescents with dismissing attachment patterns
were more likely to have self-reported anti-social personality traits. Thus insecure
attachment has its link to criminality through mental health and psychological problems and related behaviors.
Fonagy (1998) has marshaled a significant body of evidence, which has demonstrated the likely causative link between
disrupted attachment and the development of criminology. There is abundant evidence that criminality is associated with insecure
attachment and more serious crime with non-attachment (Fonagy, Target, Steele & Steele 1997)
and crime were for Bowlby (1946) disorders of attachment. In these disorders the criminal acts against others are permitted
through a lack of concern, which is a result of the inhibition of bonding.
Preliminary data from
an Australian inmate population
The following are some preliminary findings from a collaborative research project that I am involved in with the Corrections
Health Service (Dr Tony Butler and Mr Simon Quilty), and Dr. Joanna Penglase,
Ms. Katherine McFaralne and Mr. John. This research arose from an Inmate
Health Survey conducted by the Corrections Health service in NSW led by Dr. Tony Butler.
The current research focuses on data sets that capture experiences that were disruptive to attachment in the backgrounds
of adult offenders who were incarcerated at the time of the survey.
557 of total 995 inmates who had completed the inmate health survey were selected for study. This smaller group were those who had also completed the CIDI (***), a research instrument which measures
mental health indices.
The composition of this group sampled is detailed in Table 1 and shows the large proportion of indigenous Australians
in the sample is an indication of their over-representation the incarcerated population.
Table 2 shows the overall rate of any mental disordered a category of ICD 10 which is an international classificatory
system for mental disorders. The cohort examined also had an overall 12% of attempted
self-harm. (Table 3)
Data concerning the care background of these inmates (see Table 4) showed that 20 % of the total group had been placed
in care before the age of 16 years with rate for women even higher (29%). Table
5 shows the main type of care the group experienced and has you can see 15 % had experienced institutional care.
Table 6 revels the percentage breakdown of the number of times this group had been in care and it can be seen that
a significant number have experienced multiple acre placements.
In the light of the previously mentioned research the age at which the group was first placed in care is also significant
and Table 7 shows a large number had been placed in care before the age of 3 years.
The total time spent in care (Table 8) also revealed that a significant percentage of the group had spent more than
five years in care. This correlates with the findings presented in table 9 which
is the amount of time in total that was spent with parents care before the age of 16 years.
These data reveal a strong correlation between mental health problems and time spent in care.
The analysis of the data to date has shown (see Table 10) that all the listed mental health indicators are substantially
higher for those inmates who had had the most disruptions to their attachment and relatedly who had spent the most time in
care. Those who had the most disruptions to their attachment were also more likely
to be a recidivist (see Table 11).
Taken together these data corroborate the body of attachment research data, which show a clear association between
insecure attachment and mental health and insecure attachment and criminality
They also suggest a link between severely disrupted attachment occasioned by family separation and subsequently being
placed in care, mental health problems and criminality where the mental health problems apparel to mediate the propensity
The research data and extant research literature presented clearly documented adverse mental health sequalae, associated
with family separation, loss and subsequent care experiences with differential effects on mental health linked to institutional
care, foster care, and adoption. Notwithstanding this, the opportunity to form
and maintain a primary attachment subsequent to disruption to attachment, has emerged as the factor most relevant to mental
The data presented confirm that insecure attachment which ensues in various from family separation and loss can result
in a wide range of mental health problems which have in common varying degrees of difficulty in forming close reciprocal relationships. Criminality in it various forms appears to be one common consequence of severely disrupted
attachment and has a range of mental health problems associated with it that seem to underpin the propensity to offend.
There is a strong case for the body of research and knowledge concerning attachment to inform our approach the strategies
that are invoked when children are separated or loose their primary caregivers or families.
It also needs to inform policies, programs and services for those, including offenders who are struggling with consequences
of their developmental history.
The value of attachment theory as a compassionate and philosophically sound means of making connections
about the data we have concerning family separation and mental health is strongly supported by the data presented.
The next challenge may be to take this approach forward in the form of useful policies and programs for
those in need in a manner that stresses our attachments to each other in this society.
*Timothy Keogh is a Clinical and Forensic
Psychologist and Psychotherapist in private practice and has a special clinical interest in attachment disorder. He is a former Director of Inmate Services and Programs (Department of Corrective Services) Director Psychological
and Specialist Programs (Department Juvenile Justice) and Director, Inner City Mental Health Service. Tim is currently involved in a range of attachment research with the University of Sydney and Corrections