第六部分：依恋理论的过去、现在、和未来
作者：Susan Goldberg 博士
mints 编译
要点：依恋理论在改善儿童与照顾者关系方面得到了运用，并且影响了医院政策；机构护理；儿童监护权；和产妇就业政策。
我们强调了早期依恋关系对婴儿生活产生的巨大影响。我们已经看到了各种依恋模式是如何发展的，以及逆境如何影响了婴儿的依恋安全和发展结果。
我们以依恋理论对儿童生活的影响来结束这个系列。依恋理论家产生的想法和研究结果如何在家庭中和在家庭之外对受照顾的孩子产生了影响？最重要的是，依恋理论是否可以帮助我们更好地照顾孩子？
6.1 鲍尔比的世界卫生组织报告
1951年，约翰·鲍比代表世界卫生组织编写了一份报告，该报告对联合国无家可归儿童的福利方案做出了巨大的贡献。该报告极大地影响了全世界关于收养、社会工作和医院实践的公共政策。
在六个月的时间里，鲍尔比收集了母亲剥夺对无家可归或受困扰儿童生活影响的数据。他与欧洲和美国的社会工作者和儿童精神病学家进行了交流。尽管他们的背景各不相同，并且基本上不知道对方的工作，鲍尔比发现，他们的结论非常相似。也一致报告了失去母亲对孩子产生的同样负面结果。
鲍尔比的结论传达到了政府、社会机构和公众手里，强调母婴关系的极端重要性。他主张进行大规模的政策改革，并主张以财政援助、心理治疗和其他社会服务的形式提供家庭支持。世卫组织的报告影响了许多国家的社会工作做法。
在鲍尔比提出这一想法之前，孩子们往往与母亲分离，而且几乎没有任何理由。“不满意”的家庭条件，如不整洁、贫穷或母亲未婚等，足以让儿童与家庭分离。鲍尔比令人信服地指出，除了虐待或忽视情况之外，母亲的照料远比母婴分离居住好。
自世卫组织报告发表以来，依恋研究强化了鲍尔比的许多论点和建议。证明了社会支持可以缓冲不利条件的影响，有助于促进那些在不利条件下成长的儿童的安全依恋。
6.2 医院政策
依恋理论也对医院探视政策产生了重要影响。今天的参观特权与20世纪50年代和60年代初的政策形成了鲜明对比。那时候的政策不鼓励探视，并严格控制家长探视，通常每周仅限一小时。尽管有很多人反对——声称严格的探视限制对儿童有害，但最低限度的探视规定依旧存在。
早在1943年，利兹的精神病学家哈里·埃德斯顿（Harry Edelston）就声称，孩子们因住院而留下了情绪伤疤。1946年，鲍尔比与社会工作者詹姆斯·罗伯逊（James Robertson）合作，研究住院对婴幼儿的影响。他们得出的结论是，住院儿童的情感往往会因为他们的经历而遭受到了伤害。
但是，尽管做了这项工作，许多人仍然不相信儿童在住院期间所遭受的极端情绪创伤。作为回应，罗伯逊准备了一部记录片，描述了一名幼儿在医院的痛苦经历。一个两岁的孩子去了医院，一开始遭到了医疗专业人士的愤恨；但最终，医院的政策确实改变了，允许看护者拥有无限的探视权。
延伸阅读：2岁儿童去医院
6.3 机构护理
在本系列的第五部分中，我们讨论了依恋理论对收养政策的影响。许多研究是在20世纪40年代进行的，当时孤儿院在北美很普遍。研究发现，在孤儿院长大的儿童发育迟缓，表现出不正常的的社会行为和情感行为。最终，在收养或寄养家庭的安置下，功能获得了改善，但对大多数儿童来说，许多缺陷依然存在。
鲍尔比和其他人将这些结果解释为这是由于儿童被剥夺了母亲。从那时起，研究人员意识到，机构护理的匮乏不能仅仅归因于母亲的匮乏，还包括父亲、兄弟姐妹和家庭背景的缺失。尽管如此，鲍尔比的观点以及对孤儿院的研究都导致了幼儿护理机构的消亡，并且催生了越来越多的以寄养进行安置的方案。
虽然寄养制度比收容制度有了一定的改进，但并不总是成功的。当安置失败时，儿童被反复转移到新的寄养家庭后，其结果与收容儿童的结果非常相似。
6.4 依恋和儿童监护
依恋理论在儿童监护权纠纷中具有重要的地位。为了确定儿童的最佳监护安排，需要进行正式的监护评估。人们普遍认为，子女与父母之间的依恋质量应该成为监护权评估的核心部分。但对评估实践的回顾表明，人们往往不清楚如何评估依恋，甚至不清楚“依恋”一词的含义。在许多情况下，存在着对依恋理论的误用和误解。
2005年2月出版的《儿童心理学和精神病学杂志》上的一份报告显示，儿童监护权评估往往依赖于没有研究支持的措施。此外，以经验为基础的措施在实践中的地位往往有限。作者提出了在监护决定中使用依恋理论概念和措施的基本原理。他们还建议开发基于依恋的监护权评估模型。
6.5 运用依恋理论改善儿童与照顾者的关系
在本系列的第五部分中，我们探讨了依恋理论如何影响了高危家庭的育儿计划和干预措施。婴儿看护者疗法已成功用于高危人群。修改后的互动指南特别关注了与无组织依恋相关的护理者行为。
加拿大各地的一些研究正在对高危家庭、有临床问题的儿童、青少年父母的儿童以及参与儿童保护服务家庭的这种方法和其他方法的有效性进行测试。研究人员也将以依恋为基础的计划提供给了因生物、医学或心理社会风险而有发育迟缓风险的儿童照料者。
这些计划从一开始，就设计了为期八周的护理者培训课程，旨在改善婴儿护理者之间的互动，以培养依恋安全感。目前，世界各地正在制定许多其他基于依恋的干预措施。
依恋驱动的育儿方法不仅适用于高危人群，也适用于所有幼儿照料者。研究表明，大多数照料者不知道依恋的基本原则。大多数人没有意识到他们如何应对孩子的痛苦信号会对婴儿的长期社会情绪发展带来巨大影响。
此外，大多数产前教育课程并没有教受看护者的这些原则。一个简单的礼物是一盘十分钟的录像带，录像讲述了如何安慰你的宝宝，以次解释依恋理论的原理。它教会护理者何时、以及如何应对婴儿的痛苦症状。
6.6 产妇就业和婴儿护理
日托对婴儿-照顾者依恋关系发展的影响是依恋理论和研究引发的最具爆炸性的争论。依恋理论强调，长期的持续护理在最佳发育中的重要性。这对超过50%的一到三岁的母亲在外工作的加拿大孩子来说意味着什么？
6.6.1 证据
20世纪80年代，许多研究着眼于中心护理对婴儿的影响。这些研究的重点是附属于学术机构的高质量日托中心，精心挑选的工作人员、较低的婴儿照顾者比率和精心设计的项目。在日托和母亲在家照顾的婴儿之间未发现发育差异。事实上，对于一些处境不利的婴儿来说，日托提供了某些优势。
但是，在非父母照料下，婴儿的典型经历又如何呢？大多数父母都没有奢侈的能力把孩子留在高质量的精心监控的中心进行照顾。
20世纪80年代，随着家庭外护理变得越来越普遍，越来越多的研究专门关注母亲就业和各种替代护理情况对依恋的影响。这些研究发现，尽管大多数婴儿都安全地依附于母亲，但安全依附的百分比明显下降，回避行为增加。
鉴于80年代的发现，我们如何解释这些结果？
衡量母亲就业对婴儿影响的一个主要障碍是替代护理情况的巨大差异。母亲外出工作的儿童可能由亲属、家庭日托和日托中心照顾。此外，对于每一种情况，在环境中的婴儿数量、成人与婴儿的比例、照顾者的年龄和经验、身体接触数量、注意力、情感、联合活动以及这些儿童经历的交流方面都存在很大差异。
1986年，宾夕法尼亚州立大学的依恋研究者杰伊·贝尔斯基（Jay Belsky）得出结论，婴儿头几年每周超过20小时的某些形式的非孕产妇护理，会对依恋和发育有害。贝尔斯基的言论引发了巨大的争议。
尽管贝尔斯基的评论提到了产妇就业，而不是一种特殊类型的替代护理，但“日托”一词在辩论中占据了突出位置。这导致许多人担心政策制定者会忽视早期的研究，这些研究显示，高质量的护理效果是良好的，并建议削减儿童护理项目。
为了应对80年代的争议，成立了一个美国财团来研究早期儿童保育的效果。国家儿童健康与发展研究所早期儿童保育研究网络就包括贝尔斯基和他的对手。他们对9个州31家医院的1153名婴儿在15个月大时使用的这种奇怪的情况进行了母婴依恋评估。
结果显示，任何替代的儿童保育变量都不会对母亲的依恋产生显著影响。当他们的母亲在敏感度和反应性方面被评为更高时，无论他们是在家工作还是在外工作，婴儿都更有可能与母亲建立安全的依恋关系。
但托儿经历和母亲行为确实共同影响依恋。具体而言，当母亲对婴儿的敏感度和反应性被评定为较低时，低质量的替代护理、护理时间的增加以及护理安排的改变与不安全依恋有关。1999年在加拿大进行的一项规模较小但平行的研究复制了这些发现。
关于替代护理的最后一句话是：让婴儿接受高质量护理似乎不会对其发育或依恋产生负面影响。高质量的日托包括高工作人员比率、合格工人，低流动率，以及将每个孩子分配给特定的看护人。低质量护理的婴儿预后较差，尤其是当其母亲的敏感性或反应性较低时。
6.7 期待
自1951年鲍尔比发表《世界卫生报告》以来，依恋理论影响了医院、收养和社会工作政策、和育儿行为。但是，作为一个社会，我们是否充分应用了从依恋理论和研究中学到的东西？
我们对影响儿童问题的态度和政策应该以新的心理学知识为依据。这项研究证明了早期依恋安全的重要性。研究还表明，可以帮助照顾者与孩子建立更好的依恋关系。婴儿护理政策的制定应反映这一认识；然而，仍然有人强烈反对延长育儿假期、支持高质量的儿童保育计划以及为高危家庭提供足够的社会援助。
可以肯定地说，我们远远没有可以实施的、能够充分满足婴儿依恋需求的社会计划。但作为护理者，我们个人可以从多年的研究中受益，这些研究表明，早期依恋关系对于孩子健康的社会和情感发展的重要性。
Diane Benoit, MD, FRCPC
Sheri Madigan, PhD, C.Psych (监督实践)
5/14/2010
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
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Key points
- Attachment theory has been used to improve the child-caregiver relationship and has influenced policies regarding things such as: hospital policy; institutional care; child custody; and maternal employment.
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 approaches 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.
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