An attachment assessment (bonding and attachment assessment) evaluates the pattern of relatedness between children and their caregivers. It is not a therapeutic intervention, although it may be used as a basis for later therapy. The assessment should result in a description of the particular style of attachment that a child has with a particular caregiver. It should be able to describe what that style will mean in the child’s development. The observational and interview sections of the evaluations provide data to support the evaluators conclusions. The evaluation should also describe the way that other developmental information informs the evaluation.
In the evaluation, the interviewer remains neutral and politely positive. Evaluators typically feel the pull to encourage better functioning by:
helping to regulate dyads when they become dysregulated.
instructing parents who are not responding, or
increasing the positive emotional climate in the room.
The results of the evaluation are skewed when the evaluator “helps” in this manner.
These evaluations require ample time–typically 10-12 professional hours for the assessment, feedback and written report. If there is an assessment of two families, the evaluation can easily require 18 hours. The assessments are typically requested when a child is in dependency status with the State and there are placement concerns. The assessment must have observable behavioral indicators to back up the conclusions of the evaluator. Therefore, the observations are critical to the evaluation. The assessment is NOT a parenting evaluation as part of a parental custody matter and should not substitute as one.
The evaluation should include background information about the child and the placement questions. Basic information should be in-hand and read prior to beginning the observations. The areas that should be included in the evaluations are listed below. (The final written report can simply follow the order of the items below, if the assessors find the order helpful.) Evaluations usually have questions that the evaluation should specifically address. Those should be listed clearly in the final report along with the reasons for referral.
The information described in the above paragraphs should be gathered prior to beginning the observation. While a report or two may still be trickling in, the overall background of the child should be available before beginning the observation and interview process. Certainly issues like developmental delay, attention deficit disorder, autism, and brain injury are important to an understanding of children’s behaviors with caregivers.
Essential Elements in the Assessment:
Client description and reason for referral:
This will almost always be a dependency situation in which a child’s placement is involved. In most States the foster care or adoption caseworker must give permission to assess a child. Get written permission from the State caseworker if the foster parents are requesting the evaluation. List any particular questions that the evaluation is asked to address.
Sources of Information on Attachment: These should include the amount of time and dates of direct observation, phone or in-person interviews, and parties present.
Developmental History and Health/Medical Issues: Prenatal history, developmental milestones, and current functioning are all documented. If unknown, that is also documented. Prenatal exposure to substance will be noted here. Educational, Psychological, Occupational Therapy, Speech and Language, and Neuropsychological evaluations are all noted here. Describe who completed them and the dates, noting their significance to the evaluation. Diagnoses are recorded here. Maltreatment is summarized here, backed up by the written record, if possible, and more than one source.
Child’s History with Caregivers and Families: This includes a placement history and reasons for placement. The chronology should include length of time of placement with reasons for the moves. This section summarizes the people to whom the child has connections, including caregivers, siblings, and community members.
Observations best occur in the child’s home if the home is safe and reasonable as far as distance. Observations in your office can still work well. Observations need to occur in a controlled setting in which the dyad can relate closely. (In the wisdom of Vera Fahlberg, MD, do not go for fast food unless you want to know if kids like french fries.) Caregivers are not to receive calls or texts. Sometimes attorneys, sponsors, and CASAs will need explicit directions not to come. Tell caregivers that you will save time in their interview with you in order to answer brief questions about the observation with the child.
Observations should contain time in which children have the chance to play and explore, as well as feel emotional and physical needs that typically cause children to reach out for caregiver assistance. This assistance from caregivers is in the form of emotional assistance with regulation as well as the direct meeting of children’s needs. Examples are: help with a toy, delaying a child who wants to leave, providing food for a child who wants something to eat, negotiating who goes with the child to the bathroom, etc. By planning the observation periods to include normal stressors, evaluators do not have to use the excellent, but more research-oriented “strange situation.”
Dyadic Observations: There should be two, ninety-minute observations that include at least one transition in each session: to nap or bed, indoors to outdoors, to a meal, and from play to structure. If the observation is in your office, the “need” may constitute a parent’s walk up the hall for a lunch left in the refrigerator, the trip by a parent to the bathroom in which they have to figure out whether to go with or without the child, and the trip of the child to the bathroom.
In the office, the parent is cued that they are in charge of the child in this setting. After an introduction to the room and the play opportunities, the parents will be providing the play and structure.
The directions to the parents sound like this: This is an evaluation that allows me to see the way in which you and your child connect. You and your child will be spending the next ninety minutes together. My job will be to observe. Yours will be to spend time with your child as you normally do. You will help your child when he needs anything. You will be playing with your child and setting limits as necessary. When she needs something, you will be the one she can ask. When it’s time for a transition to another activity, you will be the one to decide to do that. Let me show the room’s supplies to you, so that you can select what you want for your child. When you need to go to the restroom or to get your child’s food from the office refrigerator, I will be available to stay with her while you go up the hall ( in the case of an office observation). I would like you to move him between lunch and nap or playing outside and coming indoors (put in the appropriate transitions) as you normally would (home observation).
In the office observations, ask the parent to provide food for the child. (I have a small table and chair in the office for the meal. A picnic on the floor is also fine.) One of the observations should bracket a normal meal time. If the parent starts visiting with the observer or speaking on the phone, cue (prompt) once that in this time you are interested in learning how they interact with their child. You cannot observe this during phone calls. The observer says little in the session, putting on the previously mentioned politely neutral expression. As children approach the observer, direct them back to the caregiver. Do note if and for how long the caregiver is avoided and the observer approached for the meeting of needs and/or play.
We usually begin the observation by asking the parent to choose or join the child in a play activity. Then, we move to a structured event, like getting ready to go to bed. If there are two parents who need evaluated with the child, see the child with them separately, and then together. Make certain that you see both parents, at least once, with the opportunities of play, transition, feeding, and meeting needs. (Expand the time frames to two hours.) If you are seeing siblings, split up the times so that you are seeing the siblings alone with one, and then both parents, and siblings together with one and then both parents.
If a parent is intending to live with a partner, include that partner in one of evaluations. If that partner is not intending to co-parent, they need not feed, structure, etc. However, the effect on the parent is important to evaluate.
The following lists are ones that I use to document behaviors. I note each occurrence with a slash, with a slash on the fifth occurrence. A particular behavior may have twenty or thirty marks in an observation period. Since attachment includes patterns of relationship, documentation requires noting the behaviors that inform the patterns.
Secure Style Indicators
_____Child clings to parent when uncertain.
_____Child references parent’s face for cues about the evaluator and/or setting. She is reassured.
_____Child follows parent around room with eyes, without being wary.
_____Child smiles back at parent.
_____Child initiates smile to parent.
_____Child initiates or responds to little games, playful interactions with parent.
_____Child prefers being within 3 feet of parent rather than alone, while getting used to the observer or space.
_____Child bring parent into proximity when playing.
_____Child shows enhanced enjoyment when getting parent’s attention.
_____Child reaches towards parent, and then moves towards parent.
_____Child anticipates that the parent will help when they are distressed or frustrated. They reference the parent with a look and then anticipate parental involvement.
_____Child looks to parent to share positive affects.
_____Child leans against parent and relaxes.
_____Child looks to parent when confused and then looks reassured.
_____Child climbs onto parent’s lap or overlaps parent when needing a break from stimulation.
_____At a misstep in play or a tough transition, parent attempts a repair. The child accepts the repair.
_____Child protests and becomes mildly upset when parent leaves room. Child calms quickly when parent comes back.
_____Parent calms the overexcited child with voice tones, distraction, or touch.
_____Parent organizes the child’s time, providing structure in a calming voice.
_____Parent touches child to guide, reassure, or to connect.
_____Parent uses gaze to share delight.
_____Parent’s talk allows for pauses that the child can fill.
_____Parent allows the child to introduce items into the play—then follows lead.
_____Parent matches or notes the child’s facial or body expressions;
_____Parent interprets child’s expressions indicating that they are thinking of the child’s point of view.
_____Parent distracts when child is frustrated.
_____Parent prepares child for transitions.
_____Parent’s body and voice tones stays steady, but empathetic, when child is dysregulated.
_____At a mis-step in play or during a transition, parent attempts a repair. The child does not accept it. The parent stays regulated.
_____Parent guides child through transition, speaking to the child’s feelings if the child is upset.
_____Parent sets limits if play gets too unruly. Puts items away and introduces something else.
Insecure Attachment Indicators—Preoccupied or Dismissive Parents
_____Parent talks over child.
_____Parents talks more to evaluator than to the child.
_____Parent begins to play and then drifts off.
_____Parent moves out of postures that allow child to nestle.
_____Parent sits or stands so that child cannot easily scan their facial expressions or have body contact.
_____Parent references the child’s facial expressions but does not sustain interest in them.
_____Parent talks about self and their point of view during play or transitions without trying to include the child’s point of view.
_____Child does not hold parent’s attention, with parent discontinuing the play without signaling a transition.
_____Parent complains about length of time that he has to spend with the child for the observation.
_____Parent argues with child over the play activity.
_____Parent is impatient with child’s anxiety when parent needs to leave or return to the room.
_____Parent threatens the child rather than giving limits. “You do that and you’ll be sorry.”
_____Child looks at the parent for play cues, but finds that the parent’s is thinking about something else.
_____Child asks repeatedly for needs for things, needing repetitions to get parent’s attention.
_____Child does not connect with parent’s facial affect except briefly, and then turns away.
Insecure Attachment Indicators—Anxious or Ambivalent Child
_____Parents makes statements like: “I don’t know what you want. I don’t know what to do.”
_____Parent spends a lot of time in tense silence.
_____Parent makes anxious attributions about stress on child during play or transition.
_____Parent anxiously talks about self and their point of view during play or transitions without trying to include the child’s point of view.
_____Parent announces the transition with too much advance warning, and conveys tension well before and after the transition.
_____Parent apologizes to the child for the structure rather than supporting structure.
_____Parent conveys anxiety to child with non-verbal cues and facial expressions. Sees anxiety in child and amplifies the anxiety.
Insecure Style: Anxious Resistant or Ambivalent
_____Child looks at parent quickly, and then looks away, carrying some of parent’s anxious expression.
_____Child gets frustrated with a problem in play, but does not reach out to parent confidently. May say, “you probably won’t help me with this.” Complains after parent helps.
_____Child clings to parent, but does not settle or regulate better with body contact.
_____Child climbs parent’s body roughly, with parent wincing, and with no change in child’s expression in relationship to parent’s non-verbal cues.
_____Child drums feet against parent when being held.
_____Child asks for items, but then abandons them.
_____Child discontinues gaze with parent in order to better regulate herself.
_____Child continues to signal distress long after the transition (whines, complains, bats at parent).
Insecure Style Avoidant
_____Child sits outside of social distance from parent throughout observation.
_____Child sits with back to parent.
_____Child stiffens when touched by parent.
_____Child gets frustrated with a problem in play, but does not reach out to parent confidently. May say, “you probably won’t help me with this.”
_____Child grabs toys away from parent during play.
_____Child looks at parent quickly, and then looks away.
_____Parent does not hold child’s attention, with child moving on before parent can respond.
_____Parent does not share time or activity with child. (Plays with building activity by building his/her own structure. Asks for child’s admiration.)
_____Parent asks for reassurance from child. (Am I doing this right?)
_____Parent shrugs when child ignores, excludes, or resists parental interaction.
_____Child persists with negative behaviors that are not allowed.
_____Parent is critical or sarcastic with child.
_____Parent gives up on limits and begins to ignore behaviors. Record items like: lets child use markers when sitting on floor when asked to move to table; stands on sofa when parent requests that they sit; riffles examiner’s briefcase when parents says, “no.”
_____Parent begins to use avoidance and helpless beseeching manner with observer.
_____Parent comments positively about child’s misbehavior.
_____Parent comments in defeated manner about their role in the failure of the limit-setting. Parent may become tearful.
_____Parent makes negative attributions of the child in regards to limit-setting. (For example: “She’s just like my sister, the drug-addict.”)
_____Parent asks the observer for help in overall care of child.
_____Parent describes other psychologically painful losses during evaluation.
_____Parent has the child take charge. Parent moves to play the part of the child rather than just allowing child to lead.
_____Parent does not reference the effect that above has on child.
_____Child uses avoidance strategies (covering ears, shouting, etc.) if parent describes other psychologically stressful life events.
_____Child gets angry at parent as parent describes psychologically stressful life events. (Note whether child hits or throws things at parent.)
_____Child comforts parent when parent describes other psychologically stressful life events in the observation. Note how the child’s comfort is reinforced by parent.
_____Child asks for the parent and then lies on floor, face averted from parent or face down.
_____Parents describes the effects that moving the child will have on the others in their life—in front of child.
_____Parent does not successfully move the child through transition, and abandons the goals. (i.e. gives up on teeth brushing, coat on or off, dinner at the table, hand-washing, and tasks that will cause frustration.)
_____Parent describes evaluator to be cause of these losses if the evaluation is not positive. (Evaluator has cued parent that he/she will have time later to speak without child present.)
_____Parent describes child as, “just like that. He was always that way.” Does not have a theory of mind.
_____Child watches parent warily.
_____Child makes punitively controlling comments to parent.
_____Child makes controlling comments to parent as in taking care of parent.
_____Child warns observer not to hurt or upset parent.
_____Child freezes when parent comes close.
_____Child freezes when parent’s partner comes close.
_____Child becomes still-faced when parent holds him or snuggles.
_____Child rubs parent’s breasts or genitals. Parent laughs and responds with a sexualized connotation. (Examples are: “these belong to daddy.” Or. “you’re too young for that.”)
_____Child covers genitals when caregiver comes close.
_____Child covers genitals when caregiver’s partner comes close.
_____Child covers face when caregiver’s partner comes close.
_____Child covers face when caregiver comes close.
_____Child wails and becomes disorganized when parent leaves room. Child is aggressive to parent when parent comes back.
_____Child runs around room in a frenzied manner. Gets less organized when closest to parent.
_____Child hits parent, throws things at parent, slams items on parent’s hands. (Child follows-up with a look of triumph or panic.)
_____Child runs to parent, veers away, and then cries.
_____Child appeals to evaluator when needing help with aspects of play (attach play parts together, take them apart, reach something). Continues to do this even when directed back to parent.
_____Child avoids parent gaze, looking at parent covertly. (This should be culturally interpreted for Asian or Native American children.)
_____Child looks dazed, moves in slow motion.
_____Child freezes when approaching parent.
_____Child expresses anger in observation much more than typical of age.
_____Parent scares child. Child looks scared. Parent laughs.
_____Parent does the same behavior as above, repeating the overwhelming play.
_____Child makes large motor movement to “scatter” parent away.
_____With the above, the parent does not attempt to attribute a meaning.
_____Parent gets bored, asks how long the observation is, asks to take a break and describes this time with child as onerous or irritating.
_____Parent gets tense and angry if evaluator will not watch child while she takes a break.
_____Parent does not stay for the entire evaluation. Note if she walks out.
_____Parent repeatedly moves out of social distance from the child.
_____Parent attempts to bring up subjects of interest—not finding the interaction with child interesting enough.
_____Parent brings up traumatic material into play or conversation.
_____Parent does the above, and encourages the child’s support.
_____Parent makes negative attributions about the child.
_____Parent uses the time to ask for non-child related resources from evaluator..
_____At a misstep in play, parent attempts a repair. The child does not accept the repair. Parent responds in a peer manner, “Be like that.”
_____Parent repeatedly overstimulates child, even positively.
_____Parent uses stalking movements that frighten child.
_____Parents uses too frightening a voice in play, notes that the child is frightened, but then does not self-correct.
_____Parent brings up trauma themes in play.
_____Parent dissociates during observation.
_____Parent lifts lips and shows teeth in play. Child is frightened. Parent laughs.
_____Parent and child play babies. Parent is baby repeatedly.
_____Parent asks the child to come close, and then moves further away.
Parent interviews will take an hour for each parent. Tell parents the time frame for the interview. Explain that you will be asking them a series of questions. The questions will help you to understand their relationship with their child. You are depending on the information in the interview to understand how they approach parenting this child. It will be important to stay on topic. Ask them if they have any questions from the observation. If so, give them 5 minutes at the beginning of the interview.
Give three words that describe your relationship to your child.
Give an example that describes each word.
Describe a typical day’s schedule for your child.
How does their child indicate when he wants to be close, when she wants attention, when she is afraid, when he is tired?
What does their child enjoy?
What type of temperament does the child have? (You may prompt with words that define “temperament.” For example: shy, outgoing, etc.)
What things are hard for their child? What does he do well?
What do they most enjoy doing with their child?
What events in this child’s life have been difficult and/ or traumatic?
How have those events influenced their development?
What are special concerns they have for this child?
Interviewers are looking for: coherence, conciseness, evidence supporting emotional availability to the child, their understanding of their child’s developmental needs, understanding of their child’s state of mind, self-reflection about their parenting, and realistic notions of the child’s emotional needs and how to meet them. The interviewer is not expecting people to know terms like “self-reflection” but is assessing for the qualities.
Do not overly support the parent who does not talk much. Nod, give one-word prompts, but do not do this parent’s interview for them. If the parent over talks, and strays far from parenting, give no more than two prompts to get this parent back onto the subject. Simply remind them that the interview is an hour.
If they have a child in relative or foster care, the interview is expanded to include another 20-30 minutes. They should describe how the child came to be in care. In this section, the interviewer is directive in asking questions. The evaluator is looking for a description that includes: 1. the parent’s responsibility for the events that caused a foster care placement; 2. a description of how the maltreatment and placement influenced their child’s development and subsequent relationships 3. global understanding of how their child’s needs were not met and how they think about it (self-reflection). For example “I did not think of how scared my son would be. I was immature, and went to a party instead of getting a sitter or staying home. I left him alone all night. Now I realize how that would scare him. I feel awful that I did that.” Alternately, “My neighbor never really liked me. You see, my boyfriend had chosen me, not her, so she was still jealous. She was waiting for a chance to call CPS. She saw her chance and took it. That’s how he ended up in foster care.”
In this interview, the effects of moving the child, or not, should be discussed, along with the implications that the parents think this would have for the child. Assess whether the parents can think of: the child’s interests as separate from their own; what their life will be like if the child stays or moves; what the child’s reactions will be; and what this might mean to other family members.
If the child has seemed frightened, or overwhelmed, ask the parents what meaning they attribute to your observations. The parent should be given the opportunity to reflect and to draw conclusions that include a working understanding of the child’s needs. Finally, ask the parent what goals and dreams that they have for their child, and their part in helping their child to move towards a successful future.
This is a forty to sixty-minute interview if the child is four or older. (The age includes an consideration of the development of the child.) The therapists can use a doll house, puppets, or art to help express themes. However, direct conversation can also be used. Themes that should be explored are:
Does the child feel safe now?
Where does he feel safest?
When he is sick, who takes care of him?
When he cries, does he go to anyone special, who?
Who is she missing? When she wants to see that person, does it scare her to think about seeing the person?
Are there times that the child feels afraid of the parent figure now…in the past?
How is she disciplined? Does that seem fair?
If a parent makes a mistake, does the parent ever say so? Does the parent say so to her?
Who are the child’s brothers and sisters? Are there any she most likes to be with? Who?
Who else is special in her life? (Note that younger children are so present-focused that they may insert someone they barely know, leaving out a close grandparent.) Ask for evidence.
Does he have nightmares? If so, how often? What are they about?
What makes him happiest in his days?
What is she good at?
The evaluator describes that he/she wants to know about their family. Older children are well aware when moving is the topic at hand. The evaluator says that the child will not be making a decision about where to live, but will be able to discuss it with adults who care about her. Often with older children I describe a judge and adults talking to a judge. (I often draw a quick sketch of a courtroom.) Sometimes the evaluator knows that a child will not be moving. If this is so, I will tell the child within the interview, simply because it is in the child’s best interests.
The narrative should include a description of observations and interviews, the types of attachment style the child has with each parent figure, and the meaning of those styles. If this child is so traumatized or impacted by maltreatment and moves that there would be attachment problems with any parent, this should be explained. In plain language, the narrative should include the description of what the implications are for this child’s emotional development in relationships with the parents evaluated. If the child has a disorganized attachment with a caregiver, that should be noted along with the style that is most prominent. For example, Disorganized—Secure, or Disorganized—Avoidant.
The narrative should include a description of observations and interviews, the types of attachment style the child has with each parent figure, and the meaning of those styles. For example we will quote a paragraph from the evaluation of Sally Jones and her mother:
“A small percentage of children have disorganized attachments with their parents. Children with disorganized attachments to their parents tend to be highly controlling of their parents, either in a punitive or care giving style. Sally Jones uses a punitively controlling manner with Mrs. Jones. Children who have this type of attachment style have been shown to have higher vulnerability to stress than other children. They are angrier as a group. They dissociate much more frequently than other children, which interferes with learning to problem-solve, cope or even avoid risky situations. As a result, research shows that they are an at-risk group both for future traumas and negative impacts from traumas. Children with these styles are often more unsettled by their parents than helped, as Sally demonstrated. They do not have a parent who can consistently help them to calm down, problem-solve, or tolerate stress. Children with such attachment styles show a long-term vulnerability in emotional and social adjustment. It often interferes with learning from adults in the educational system. Children with this style have high rates of psychopathology as demonstrated over a series of studies by researchers. This attachment style has a high likelihood of inter-generational transmission unless Sally has the opportunity of forming an attachment with another person capable of a secure base attachment.”
In plain language, the narrative should include the description of what the implications are for this child’s emotional development in relationship with the parents evaluated. In a report, I would have referenced the research literature in order to back up my concerns.
Describe you credentials in making your recommendations. Discuss the report. The report is political. You may be called to witness in Court or to appear in meetings if the child is in Dependency. Be aware of this if you are asked to do an evaluation from another State.