Exposure and Attachment

Most simply, attachment is the interconnectedness between human beings.  Central to long-term social development, attachment theory says that all children have attachments – either positive or negative – but all children have attachments.  Positive attachments are protective, while negative attachments place children at high risk for long-term social/emotional outcome.  

For successful attachment to occur, there are two requirements:  each individual must be able to read the other’s cues and each individual must be able to respond appropriately to the other’s cues.  These thoughts came to mind as I read a recently published book, When Mama Can’t Kiss it Better by Lori Gertz.  In it, Lori tells the emotional and gripping story from the time of her family’s adopting a beautiful newborn girl through the time seven years later when the adoption disrupted and the child was moved to another family and another state where perhaps her needs could be better met. 

Briefly, Lori and her husband Craig met and worked with a birth mother throughout a good portion of the pregnancy and were present for the delivery.  There was no history of drug or alcohol abuse in any of the information Lori and Craig were able to gather, but from the moment of birth the baby showed a classic picture of severe neonatal abstinence.  The doctors caring for the infant didn’t recognize this, nor did Lori and Craig, who quickly became enamored of the baby girl in spite of her incessant crying, irritability, and screaming.  By just a few months after the birth, Lori and Craig found themselves in an endless cycle of seeking help from one doctor after another.  And,  similar to many adoptive families, the couple were repeatedly told the baby was merely fussy, the baby was allergic to a variety of foods, the baby would be fine, and, ultimately, it was their fault the baby was like this.

When the infant was three years old, Lori and Craig and the family underwent a comprehensive evaluation.  This was only after they learned from the birth mother’s brother that there had been heavy alcohol and drug use throughout the pregnancy and that the birth mother had recently died of a drug overdose.  The child presented to the clinicians with severe behavioral difficulties, most of which went far beyond anything that could even remotely be considered “normal.”  I won’t go into the specifics of the family’s daily life; the book spells it out in agonizing detail.  But imagine a worse case scenario.

The profound impact of the child's prenatal alcohol and drug exposure on her developmental and emotional functioning came to light through the evaluation.  The most unexpected diagnosis made, however, was that the little girl at three years of age was suffering from a severe attachment disorder.  This is surprising on many levels.  First of all, the child from the moment of birth had been with one family who loved and adored her.  Second, from all that could be discerned from our clinical interviews and assessment with the family, Lori and Craig had done everything possible to support and nurture their daughter.  In most cases like this, quite a bit of blame is laid at the feet of the parents, especially the mother.  Their personalities and family backgrounds are dissected, the mother’s strengths and, primarily, her weaknesses are laid out.  If the mother had been a better mother, the child never would have developed an attachment disorder!  This was the message that repeatedly had been given to Lori from multiple different professionals.

But we have to look at this from a different perspective.  Attachment is a two way street, and not only must the caregiver be able to read and respond to the infant’s cues, the infant must be able to read and respond to the caregiver’s cues.  When an infant’s neurobehavioral functioning is disrupted by the effects of prenatal alcohol and drug exposure, that infant, to one degree or another, will not be able to participate in the give and take dynamic required for attachment to occur.  Too many times, and in too many different ways, our preconceived notions of what a “good” mother is get in the way of our objective analysis of a clinical problem. 

These issues are especially pertinent as we face a resurgence in opiate use during pregnancy.  Not only heroin but prescription drug abuse is reaching epidemic proportions in some states.  Infants prenatally exposed to opiates go through a true abstinence, characterized by irritability, tremors, crying, sweating, diarrhea, and, in some cases, seizures.  Infants going through opiate abstinence often will not be able to respond adequately to touch, voice, or face-to-face interaction.  In fact, the infants can easily become overloaded and demonstrate escalating stress.  Under these conditions, the infant will not be able to read the caregiver’s nurturing cues or respond appropriately.  When the caregiver does not receive positive feedback and reinforcement from the infant, he or she tends to begin to back off; the dance of attunement between caregiver and child ends in frustration and mounting stress on both sides.  Through guidance by a professional, families must learn to read the inner life of their child, understanding that the child’s behavior is not a rejection of the caregiver but is biologically based in the functional changes induced in the developing brain of a child prenatally exposed to opiates.

This is not an endorsement of a particular book, for from reading it we know only one side of the story and the little girl, now age seven, will never be able to give us her perspective.  But heartbreak can be packaged in many different ways.  In this case, heartbreak is packaged between the covers of a book.