Monthly Archives: January 2014

More Comments on Day Care, Attachment, and Separation


Another IPMH graduate, a doctor, Maria Veronica Mingo, wrote:

First, I found it so valuable that the director has written to you with her concerns, looking for ways of doing better work with their children.

I do not know what she meant by “Do you believe that early child care (before 3) undermines security of attachment?” Does she means it undermines security of attachment with parents or the child’s attachment in general?

In this regard, I think it is important to keep in mind that the child could have different kinds of attachment (ABCD) depending on the relationship. This makes it hard to talk about an “overall child’s attachment” or a “general attachment”. This point might help the director open the door of variability and diversity of relationships. It could also help to broaden the meaning of “healthy relationships” (since having an insecure attachment is considered “normal” too, in contrast with disorganized attachment).

I can imagine that child’s attachment with parents might not change before and after a child care experience (though I do not know the data). And I think it is expected that the child could have different kinds of attachment with parents and teachers. I could even imagine that the child could have different attachment with different teachers of his/her classroom! It is complicated – hard to measure and even harder to draw conclusions about it. Moreover, attachment could change over time, with parents or/and teachers, so the “one shot” strange situation measure has to be read carefully.

Another point is that behind this kind of discussion there is a kind of fear of insecure attachment and an idealization of secure ones, without understanding that attachment status is a particular way of viewing relationships that is limited in theme and time, in relation to a child’s development as a whole. It is as if the child having an insecure attachment with one teacher means that his entire capacity for secure attachment is undermined.

In this case I think it could help to think about what kind of skills or behaviors (regarding expressed needs, met needs, expressions of emotions, etc.) is required for a child’s healthy development in a childcare setting? What would impact his/her attachment with teachers (all teachers or some of them?) in some way (for better or for worse?) In the end, we do not know what particular attachment related behaviors will work for the child. Maybe, being less open in expressing needs and finding comfort from an adult (being seen as insecure attachment of a child with his teacher) could be, in some case, a good adaptation and benefit the child. I don’t know, it is something to reflect on.

The last point is that I infer from the director’s words anxiety about children’s experiencing stress when separating from their parents. In this case I believe that we could bring Dr. Tronick’s thoughts about stress (in good enough amount) and its benefit. It could help her think about the diverse expressions of a child’s distress – in kind and in intensity – and how important is to be able to be sensitive to the child in those moments; that is how trust is built, slowly, over time. It might be good for a child, who experiences high distress after separation, to know/to learn that also other people can meet his needs and that he can be safe in other places and with other people. This could take time and it might be hard for the child, the parents and the teachers but, it will have a good ending and it will be a great gain for child.

Finally, I think that shifting the focus to sensitivity to the child’s needs rather than attachment could help.

Dr. Mingo found a meta-analysis of day care studies and attachment. I found it to be an interesting and balanced examination of 40 studies including almost 3,000 children in some kind of nonparental day care – both home based and center based day care. Important limitations of the study, acknowledged by the authors, include the fact that important correlates of attachment security such as parental SES (socioeconomic status of the parents) were examined in only a few of these studies. Also, the time in day care was not usually considered.

Ahnert, L., Pinquart, M., & Lamb, M. E. (2006). Security of children’s relationships with nonparental care providers: A meta?analysis. Child Development, 77(3), 664-679.

Another IPMH grad, Marilyn Sanders, a neonatologist, writes this comment and promises to write more later:

This director has raised some fascinating questions. I will send you a response over the weekend. It will likely be based in a combination of my typical pragmatism, theory, and evidence. As a starting point, I will state that the question of whether or not to place an infant in some form of early care, be it in home or out of home, is no longer even a choice for most US women since our social policies do not support women to be home with their infants.

And, finally, another IPMH grad, Terri Lear, the Executive Director for Family Attachment, comments:

It is important to think about attachment and early childcare in the right
way. Early childcare does not impact attachment (not in a way that you might
think). Attachment impacts early childcare. The fact that a child needs to
be cared for by another person before age 3 does not guarantee or create an
insecure attachment. What matters most is the foundational relationship the
child has with his primary care provider (usually the mother) and the
quality of that relationship. Securely attached children do better in a
childcare setting, but it is not the childcare setting which “caused” the
secure attachment. It is the quality of the relationship at home which
impacts the child’s coping skills (the child’s ability to self-regulate) in
the childcare setting. Yes, it is true that children experience stress when
separated from their primary care providers, regardless of whether their
attachment is secure or insecure. This is a fact that cannot and should not
be changed. The child who experiences no stress when separating is much more
of a concern because that child may not have formed any attachment at all.
Stress upon separation can be mild or severe. Examples of mild signs of
stress upon separation is for a child to behave in a shy manner, to require
the parent to reassure him that she will pick him up after work, to make a
plan for what they will do after that pick-up (e.g., then we will go to
McDonald’s or to soccer practice, etc.), or for that child to make contact
with a beloved teacher or good friend to soften the separation stress. Some
children require a transitional object (“lovie”) to come to school with
them. Teachers should not coerce children to put them away until they are
ready, but lovies are precious and cannot be lost. So the child should be
made aware that the lovie should go to its safe place during certain

Children who are highly stressed may be experiencing a bad day, may not be
feeling well, may have something unusual going on at home, or may have an
insecure attachment which causes them to feel alarmed and uncertain about
whether or not the care provider will be there as promised. Perhaps there is
a history of the care provider not  being reliable or available (physically
or emotionally) for the child. This would cause the child to be extremely
stressed and difficult to console upon separation. We cannot know if the
parent needs to return to employment for financial reasons or for more
personal reasons (they just don’t know how to connect with a young child and
feel more comfortable in their professional setting). This inability of a
parent to relate to, connect with, attune to–whatever you want to call
it–will reveal itself in many ways in the child’s behavior and it is out of
the realm of a teacher’s capacity to change.

To answer your question about how to make separations easier, the first thing that could be done is to
make reunions better. Parents should be encouraged to take 20-30 minutes
after each reunion to not make dinner, not rush out to the store, not turn
on the TV or the laptop or the iPad/iPhone/iPod, and to just sit with their
child(ren) and talk about the child’s day, read together, or just cuddle and
make small talk. This investment of 20-30 minutes a day goes a long way
toward saving bedtime battles and perhaps is a good start at creating that
strong connection which will endure separations more readily.

Terri Lear, PhD
Executive Director
American Foundation for Family Attachment, Inc.

You can see why I appreciate so much my connection with the Infant Parent Mental Health course and the excellent colleagues I meet in the course.

Preschool, Day Care: Attachment and Separation


I have promised to discuss interventions for childhood constipation and soiling, but I received a great comment that I would like to address first.

A reader of the blog commented:

As the director of a Montessori school in Colorado, I have a few questions:
1) What are your thoughts about early child care and its effects on attachment? I am aware of Belsky’s study and the NIHCD studies. Do you believe that early child care (before 3) undermines security of attachment? Do you believe this is irrespective of the type or quality of care? Is there other research on this issue that you would recommend?

2) I know there have been a lot of studies (some even specific to child care) which show that infants/young children separated from their parents show abnormally high cortisol levels and lower growth hormone levels. Given these studies, do you have a recommendation as to an optimal way to transition a young child into a child care setting (to minimize their distress)? Is there an optimal way for children to separate from their parents each day (we have tried many things over the years- parents walking their child into the school, children leaving their parents in a car line- a teacher comes out to get the child, etc)? If a child appeared to be highly stressed (how would you quantify this?), what would you recommend? Is there any research as to how specific practices might increase or decrease a child’s experience of separation?

In response to this important comment, I contacted recent graduates of the Infant Parent Mental Health course in Boston and Napa, of which I am on the faculty – I value the knowledge and expertise of this group of clinicians and wanted to start a discussion about the issues of childcare, security of attachment, and separation from parents. I will also request comments from another group of valued colleagues – preschool teachers.

My first response came from an IPMH graduate who also has extensive experience directing and administrating early child care programs, Alayne Stieglitz. Here is her thoughtful response:

When I read these questions I thought of Ed Tronick on the first day of the IPMH Program introducing us to the caregiving practices of several cultures around the world: The village in the Andes where infants are bundled in blankets and strapped upside down on their mothers backs for the first year of their lives and the tribal group in Africa where children have an average of seven caregivers before their first birthday. These are not what we would consider ” best practices” but the children there are reaching their developmental milestones, forming healthy, robust attachments, and thriving in their societies. He said, “Different patterns of care taking and parenting may violate norms we hold as vital, yet children are still developing and learning. Those differences work for their culture. The point is to raise a child who can be competent and successful in the culture they live in.”

In this day and age, the culture that an increasing number of families are living in includes childcare. Single parent households and households where both parents work in order to provide what’s needed for their family do not have the option of whether or not to put their children in someone else’s care. There are many choices; in home care by a relative, in home care by a nanny, small family day care, and center based care. I think the question to ask is not, “Which type of care is best?” But, “Which type of care will be best for my child and my family?” And, of course, “Which is the highest quality of care that I can afford?” This last question limits the options for many families. Continue reading

Constipation in Young Children


A problem that captures the complex intermingling of biology and psychology is the problem of chronic constipation and soiling in young children. This is not an infrequent complaint of parents in my practice.

Psychological Factors:

Often chronically constipated children had initial difficulties in toilet training, for example, refusing to poop in the toilet and demanding a diaper, even sometimes insisting that their parents put a diaper on them just for this function.  Sometimes the children seem to be afraid of pooping in the toilet, fearing the loss of their poop as if it were still a part of their bodies (a common confusion related to the child’s cognitive immaturity), or fearing the swirling of the water taking the poop down into some unknown place, and the noise of the toilet flushing. These worries are common and not “abnormal” and only cause problems when they become extreme and chronic. Often children cannot articulate why they are afraid or do not even know what they are afraid of. Instead, they can appear to be obstinate.

Children also typically fear a loss of control in relation to defecation. Again, the fear of losing control only becomes a problem in extreme cases. Sometimes children feel more in control of their bodies and body experience if they can maintain their infantile habit of defecating in their diapers. Loss of control of their bodies can get mixed up with fear of loss of control of inner feelings and impulses, such as angry feelings and aggressive impulses. According to this (unconscious) reasoning, “letting go” refers to more than the child’s anal sphincter, but also to what the child perceives as a destructive, internal ball of anger and aggression that can explode outwards if the child doesn’t hold on tight. The child’s fear of letting out the “bad stuff inside” can cause her to fear loss of the caregiving relationship, or – in concrete terms – the disappearance of the parent! You can begin to see how a process as universal and commonplace as toilet training can hide within it dark and complicated fantasied dangers!

The child’s sense of losing control of his poop can blend into the control struggles all children and parents sometimes succumb to when parents have to set limits on children’s behavior or demands.  So toilet training can become a battle of wills. Interestingly, this is more often the case when children have additional reasons for feeling out of control – when they have developmental quirkiness that makes them more emotionally fragile and more dependent on their parents, when they have sensory over-reactivity that makes them constantly uncomfortable in their bodies, when they are generally timid or fearful, or when there has been a recent loss or disruption in their caregiving relationships. Again, children often are not aware of the feelings and frightening beliefs that cause them to resist their parents’ entreaties. They just refuse to comply.

Biological Factors:

A common consequence of children’s fears of pooping – whether related to their fears or to established struggle patterns with their parents  or both – is that they withhold their poops. This withholding has biological consequences. A fecal mass can accumulate in the child’s rectum and colon, distending the abdomen and giving the child a tummy ache. As the poop loses water in the large intestine, it becomes hard, and this plus the large size of the accumulated feces, makes it very painful to poop. Of course, this pain increases the child’s fear enormously! In addition, newer liquid stool can leak around the hardened stool in the rectum and cause soiling. Usually the child is unaware of this when it is happening, but it can cause big problems in school and at home.

A wonderful explanation for how withholding stools causes distention of the rectum and loss of the impulse to defecate is given in the website  I would highly recommend the “The Poo in You” short video on this website that can help parents and also some children understand the mechanics of the process and how to develop healthy habits. Sometimes medicine can help soften the stool and draw water back into the colon and rectum to facilitate the passing of the fecal mass.

The video also emphasizes the fact that it takes time for the rectum to recover from this distention – as long as a year of treatment. This is important because sometimes in my experience, doctors and parents discontinue the treatment too soon, with the result that everyone gets discouraged when the symptoms come back. Of course, it is not only the rectum that needs time to recover; the child needs time to “practice” the new and healthier way of pooping, and the parents need time to practice supporting their child in doing this.

Psychological and Biological Factors are Interdependent 

Sometimes the child is so afraid that even when good medical treatment has been established, he or she cannot “let go” of the poop. Then, a psychological helper (therapist) is needed to diminish the child’s frightening fantasies of “the bad stuff” inside of him or her – ideas of poop mixed up with the child’s angry feelings and aggressive impulses. These “fantasies” are not in the child’s conscious mind and are not usually even coherent thoughts. This therapeutic work is done in play therapy in which the therapist engages the child in pretend play with messy, angry, and aggressive themes. For example, the child may make a play in which “bad guys” steal gold from “good guys”, with a lot of (pretend) violent battles. The play themes are initiated by the child but the therapist helps the child manage his fears and hold the frame of pretend so that the child can create an elaborated representation of the fears. This capacity to actively create a representation in play of otherwise unimaginable frightening feelings can transform the child’s experience from helplessness to mastery.  When this is accomplished, the child is not only free to let go of her poops, she is also free to move on with her development.

I want to add something about children with disturbed or uneven development, including but not only children on the autistic spectrum. These children often do not have the capacity to interpret signals from their bodies in an effective way. For example, often they do not “know” they are cold outdoors or do not feel the urge to urinate. These children are at special risk of getting constipated.

In my next blog I will address the issue of treatments for the anxious child that I promised to deal with at the end of that posting


Being the Parent of an Anxious Child


Recently I heard an author and editor of The Atlantic magazine, Scott Stossel, talk about his severe anxiety ( Stossel, 2014). What struck me about his story were two things – his description of having had serious problems with anxiety since he was two years old, and also how terrible his anxiety was. He said that the feeling of dread was sometimes so intense that he didn’t think he could go on living. In response to an interviewer asking him what he had found that helped, Scott spoke compellingly about how the first step was accepting the fact that there is no cure, that one has to develop a repertoire of coping skills to deal with the issue and recognize that sometimes you will be OK and other times you suddenly and drastically will not. He even referred to his condition as “temperament”. This rang so true to me.

I pondered on the sweet children I have seen over the years who have had severe anxiety. Some of them have gotten better, and some of them – “stubbornly”! – have not, or at least, are still up and down. Scott Stossel correctly described the problem as a spectrum. All of us have anxiety, but whereas for some it is typical nervousness related to environmental stressors, for others the anxiety is debilitating. I will discuss the treatment of these conditions in another blog posting, since I disagree somewhat with his sense of the limitations of treatment. Right now, I want to talk about the role and the experience of parents with an anxious child.

First of all, I agree with Scott that this problem – barring cases of posttraumatic stress – is largely an issue of temperament. Jerome Kagan and Nancy Snidman talk about how the newly recognized “sensory reactivity disorder” can be seen as a feature of temperament, since both the sensory disorder and also high reactive temperament, have significant heritable features. I don’t say, “inherited”, since we know that the matter isn’t as simple as that. Environmental (and epigenetic) factors have an important role even in the womb, and certainly after birth, when anxious caregivers have a powerful effect on the developing capacity for self-regulation in the infant (Nelson, 2013) (Beebe & Lachmann, 2013). Individual differences tend to be a “blend of temperament and environment” (Snidman, 2011). It appears that the part of the brain that registers threat in response to environmental stimuli – the amygdala – has a lower threshold of reactivity in these children. It is well known that high reactive temperament and the related insufficient development regulatory competencies may complicate a child’s attempts to cope with adverse life circumstances and even everyday transitions (Kagan et al, 2007, Kagan, 1989).

What I would like to focus on here is the effect of an anxious child on his parents. I am not referring to parents just getting anxious when their child is anxious. I am referring to complex patterns of emotional communication that are initiated in infancy and become established and then have a continuing influence on future development – both of the child and of the parents – so that over time, the trajectory of development and associated behaviors become increasingly distorted (Beebe & Lachmann, 2013) . And the people involved don’t even notice it, because they are so intent on staying connected. Many parents of super anxious children tell me that they “walk on eggshells”. What they then explain is that they are afraid of triggering an explosion in their child. But, what I think they really mean is that they are afraid of losing the connection, afraid of losing the child.

Also, they get worn down. When you “lose energy”, as in all living systems (which humans are) you tend to retreat to a simpler but less complex and effective level of functioning.  I don’t use the word “regress” because that could imply a global move to a previous level of functioning, whereas when I use the term “retreat” I mean that the idea that the higher level of functioning remains in the individual’s repertoire but he/she does not at that point have enough energy to attain and maintain it. In my practice, I sometimes talk to parents about “being on the front lines” in an attack. If things are not going well and you are in the front lines, you may tend to just shoot rather than – from the more protected position of the generals – plot new strategy.

So from the beginning, when the child cannot sleep or has trouble with feeding, the parents bend over backwards to help the child sleep – such as sleeping with the child – or eat – such as accommodating severely restrictive diets. These parents are trying to protect their child’s survival. However, what they can’t allow themselves to realize at the time is that they are contributing to the distortions that are developing. The child who will explode if you don’t accommodate his demands does not learn to tolerate frustration. The child who “only eats chicken nuggets” doesn’t learn to like other foods.

Before you begin to blame the parents, though, consider what it means to have a child who “will” not eat, “will” not sleep. Sooner or later, you give up and accommodate the child’s demands. That is, unless the parents have support in changing these pernicious patterns.

The support the parents need is in the form of relationships. There are many therapeutic techniques that are recommended, but I am skeptical of all of them that follow manuals and are short term. The children who get better from these techniques – and there are some that do – are on an “easy part of the spectrum”. The parents of children on the hard part of the spectrum need ongoing support to change their responses to their children. They need the support of a long-term therapeutic relationship that encompasses them and their child. I will continue with this subject in a future blog.


Beebe B, Lachmann F (2013). Origins of Attachment, New York: Taylor & Francis, pp. 95-139.

Nelson C A (2013). Biological embedding of early life adversity, JAMA Pediatrics Published online October 28, 2013 E1

Kagan J (1989). The concept of behavioral inhibition to the unfamiliar, In Reznick, J, Ed., Perspectives on Behavioral Inhibition, University of Chicago Press, pp. 1-25.

Kagan J, Snidman N, Kahn V, Towsley S ( 2007). The Preservation of Two Infant Temperaments into Adolescence, Monographs for the Society of the Research in Child Development, 72 (2).

Snidman N (2011). Lecture on Temperament, U Mass Bos Infant Parent Mental Health Post Grad Certificate Program.

Stossel S (2014). My Age of Anxiety – Fear, hope, dread, and the search for peace of mind. New York, Random House.


Being the Parent of a “Problem Child”


Recently, the perfectly wonderful mother of “Sam”, an adorable, intelligent, but quirky 8-yo child, told me a sad story. The mother of another boy in Sam’s class appeared at her house with a list of alleged “bad things” Sam had done to this child. The list of Sam’s misdeeds included crimes such as pulling the other child off a climbing structure and calling him stupid. Since Sam had described his version of some of these incidents to his mother, she could imagine what had been going on. Desperate to play with the boys in his class, Sam would sometimes get frustrated when his overtures were rejected. Sam, who had trouble regulating his motor activity and attention, could be impulsive and grab or push, and he would sometimes appear to ignore another person when he was focusing on something else. The other mother told Sam’s mother to tell Sam not to try to play with her son any more.

Of course, Sam’s mother was heart broken for Sam. She was also lonely herself, feeling increasingly alienated from the mothers of Sam’s classmates. When Sam was younger, he was sometimes invited on play dates and usually included in birthday parties, but now that he was older and his behavior continued to present problems, the invitations were increasingly scarce. She felt that the other mothers avoided her at pickup time, as if they were afraid that she or Sam might suggest a get together. She envied their happy chatter as they greeted their children and made plans. Pickup time for her was always laced with apprehension – what bad news would she hear today?

She readily acknowledged her own impatience with Sam when he would not “listen” to her, when she had to ask him multiple times to do something, and when he would stop in the middle of a task like getting dressed and become immersed in another activity. Sam’s teacher suggested that he might have ADHD and medication might help, but she and Sam’s father were reluctant to “medicate” Sam. At this point, however, she was willing to consider anything. She hated it when she lost her temper at Sam and yelled at him. It made her feel like a bad mother, especially when she saw his crestfallen expression and knew he realized that he had made a mistake. She worried that he was beginning to think of himself as a “bad boy”.

Leaving aside for the moment the question of ADHD and whether Sam could benefit from medication, I would like to focus on his mother’s experience and the intolerance of the other mother. First of all, let me say that it is understandable and even essential to protect your child, and if he perceives himself as being bullied by another child (pulled off a climbing structure, called “stupid”, not listened to when insists he “needs space”) a parent will naturally take her own child’s “side”. But here is where that mother is both failing to “imagine the mind of her child” and also missing a teachable moment of great importance to her own son.

The other child, let us call “Ted”, is upset with Sam. Most likely, though, he is upset for many reasons. The typical, and more general reasons include the fact that Sam “isn’t listening to ‘no’”, and he is intruding on Ted’s space, which most people find stressful. We do not know the other unique reasons that Ted has to be angry with Sam, but there are many potential ones. For example, maybe Ted has a younger sibling towards whom Ted has intensely ambivalent feelings and who always wants to play with his “big brother”. Or, Ted and his mother have generated a pattern in which one of the main ways Mother shows her love for Ted is to (over) protect him; maybe his father is somewhat distant and has been unable to fill that protective role for him. Or, perhaps there is marital conflict in Ted’s family that pulls Ted and his mother together in order to give both of them comfort since comfort from his father is not forthcoming either to his son or to his wife. Or, maybe Ted’s mother herself feels victimized in her life and expects her child to have the same fate. There are many, many possible reasons, but even without knowing them in this particular case, we do know that Sam’s behavior is not the whole story.

If Ted’s mother just goes with the simple and concrete reason (Sam is bullying him), without trying to imagine what else is going on in Ted’s mind, she will not be able to respond to him in a growth enhancing way; she will only “side with” the more infantile “meaning” Ted makes of his distress. She will lose the amazing opportunity to help him move forward in his development – to help him become able to “imagine the mind” of a peer.

In the preschool where I sometimes work, the teachers constantly try to support the children in taking this step. First they validate the offended child’s (let’s make a new child, named “Jane”) feelings and comfort her. “Of course you got upset when ‘Joe’ – another name we made up – grabbed away your toy!” But then the teachers almost always take it one step further. Teacher: “Could we ask Joe why he grabbed it?” Jane: “Joe, why did you grab it?” Joe: “Because I needed for my castle.” Jane: “But I was using it.” Joe: “Oh.” Jane: “And it was scary when you grabbed it.” Joe: “Oh.” Teacher: “Joe, Would you like to say you’re sorry to Jane?” Joe: “Sorry.” Teacher: “Jane, does that make you feel better?” Jane: “Yes.” Look at how much learning can take place in this kind of exchange, and compare it with what Ted learns when his mother rescues him and vilifies his peer.

Even more, the black and white attitude that Ted’s mother takes in making Sam a “bad guy” also misses an opportunity to teach Ted about shades of gray, a crucial lesson in lifelong learning that builds flexibility and compassion – both for the other child and also for himself.

I will write more about Sam’s mother’s experience and the challenges she faces in a subsequent blog.

Read this blog in Spanish.