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Fostering Successful Attachment in Intercountry Adoption

Adoption Advocate No. 86


Attachment is the glue that establishes the connection between a child and a parent. When a child is born and remains with a biological parent, bonding and attachment begin immediately. With adoption, however, that is not always the case. In intercountry adoption children often face multiple broken attachments, causing them to lack the foundation on which to build healthy relationships later in life. In cases of adoption, early attachments are too often disrupted or broken. Positive, consistent relationships with early childhood caregivers and, later, adoptive parents can help reestablish a child's healthy attachment abilities.

The Basics of Attachment

To understand how to foster healthy attachment for children adopted internationally, it is important to understand the heart of the subject at hand: attachment theory. According to Bowlby, a pioneer in attachment theory, attachment is a biological, motivational system that develops within humans during our early years of life. This system is what stimulates children to try and find security, support, and care from specific "attachment figures" in their lives.1 In her first year, when the child becomes selective about which person she seeks out to provide these things, "selective attachment" occurs. This person the child has selected becomes a "secure base," meaning that she will use this person as a "home base" of sorts to venture out from and return to at any sight of "danger."2 When parents cultivate healthy and secure attachment relationships within their children as infants, they in turn cultivate an "internal felt sense of safety and trust, and an emerging sense of the self."3 Attachment, then, is not only important to relationships with parents and family members, it is also essential to children's forming relationships in the world around them.

Children who are adopted internationally can experience disrupted or broken attachments in several ways. To be placed for adoption domestically or internationally, a child must first experience a broken attachment between their initial caregiver(s), their biological parent(s). In many countries where intercountry adoption occurs, children then reside in institutions, where disrupted attachments are far too common – if attachments are first able to occur at all. Due to high staff turnover, a low caregiver-to-child ratio, lack of caregiver training, and staffing systems that do not always prioritize attachment, children are often unable to establish positive and secure attachments to adult caregivers. Even something as well-intentioned and potentially helpful as short-term humanitarian projects, by which volunteers can visit and work with orphans (sometimes referred to as "orphan voluntourism"), can have the unintended consequence of serving as just another broken connection for a vulnerable child.

It is critical that children establish key relationships with parents or caregivers in the first two years of their lives in order to lay the groundwork for attachments in all future relationships. But in institutions, these bonds are not always possible to establish. Research has shown that in certain countries, children adopted internationally from institutions have a higher risk for later diagnosis of Reactive Attachment Spectrum Disorders. The breakdown of attachment abilities in children who spent years in institutions can be attributed to a number of factors, including the lack of secure and consistent relationships with caregivers. How can a child be expected to transition directly from an orphanage where they might lack consistent interaction, nurturing, or one-on-one care to a brand-new country, culture, and family and immediately feel attached?

Early attachment for children awaiting adoption can be enhanced by implementing a foster care model when at all possible – or, in the interim, a family care model within institutions. Both of these options help foster trusting, consistent relationships. In addition to outlining factors that presently influence disrupted and broken attachments in intercountry adoption, this article will highlight successful examples of organizations that are already using a foster care model to meet the needs of children who lack permanency.

Foster Care as a Family-Like Environment

Every break in attachment a child experiences makes secure attachment once they have achieved permanency more difficult. When a child is unable to be placed in an adoptive family immediately after separation from their family of origin occurs, the best alternative is to simulate a family-like environment to help establish positive and secure attachment habits – such as a foster care model, in which children are nurtured in a family setting.

Foster care in the United States has been established as a system with the first and foremost goal being the reunification of children with biological families whenever possible. Foster care models may look somewhat different in countries that are partnering with the United States to facilitate intercountry adoptions – the idea of placing children in a home, a family-based environment, where they can receive individualized care remains the same, but the end goal would be safe and permanent adoption.

The success of any foster care model relies on having responsible and dedicated caregivers who are invested in the child's long-term wellbeing. While children stay with a foster parent or foster family, the goal is for them to meet the "child's need for an emotionally available, committed, and responsive caregiver."4 Since children who are placed in foster care have already experienced a break in attachment, it is vital that their foster parents are steady and secure attachment figures. Using this international foster care model, foster care acts as a gateway to allow children to develop an initial ability to have positive attachments. Dozier recommended that "caregivers should receive support and training regarding how to demonstrate nurturance and commitment to the children whom they raise."5 Cole conducted a study on infants placed in foster care in the United States and discovered that "infants can and do develop secure relationships with their foster caregivers."6 This study demonstrated a matching curve between the general population and children in foster care in the United States in terms of being able to establish secure attachments with caregivers.7

According to this research, placing children in foster families is effective in allowing them to establish secure attachment patterns. Under the conditions of a foster parent being well-trained, responsible, and committed to the child’s long-term future, implementing this foster care model for children in intercountry adoption can increase the ability of children to create secure, lasting attachments once they find permanency and decrease the likelihood of attachment disturbances.

In China, several organizations already use something like a foster care model with the children in their care while they are waiting to be adopted by American families. The Morning Star Foundation in China takes in infants with congenital or acquired heart defects and provides them with medical care that they need, pairing them with an "ayi" to be their one-on-one caregiver. The children are then able to form strong bonds with their caregivers, which gives them the foundation they need to be able to establish healthy relationships later in life. Similarly, in China and Hong Kong, Love Without Boundaries (LWB) has foster care programs that take children out of orphanages and place them with dedicated and nurturing Chinese families. According to Victoria Tucker of LWB, most children in these foster homes are eventually adopted internationally, but they have also noticed a recent increase in domestic adoptions. Tucker stated that "a family setting is something that [they] believe every child should have the opportunity to experience, (hopefully through adoption!)"8 These two organizations have both seen great success in helping children establish secure attachment patterns through foster care models that lead to intercountry adoption.

Because foster care is the closest family-based alternative to children having permanent families, it is the best option for establishing consistent and secure attachments with children waiting to be adopted. However, foster care should remain a short-term solution whenever possible. When a child is moved from foster care to his adoptive family, another break in attachment will unfortunately occur. Broken attachments are still traumatic, but learning to form secure attachments in the first place is important.

Transitions from a foster family to an adoptive family can be eased by introducing the concept to the child in age-appropriate ways – through visits, communication, and photos from the adoptive family, and a transition plan that might involve just a night or two away in a nearby location before the full, permanent transition is made. In some cases, there may be value in maintaining communication or some kind of ongoing relationship with the foster caregiver. In the long term, children who have seen consistent attachments modeled through relationships with their temporary caregivers – whether foster parents or institutional caregivers – will likely be more able to form attachments with their adoptive families.

Caregiver Inconsistencies and Attachment in Institutions

Inconsistent caregiving in institutions makes it incredibly difficult for children to develop the ability to create healthy and secure attachments. In certain institutions, staff turnover rates are high due to the long hours and strenuous work. Some caregivers will work 24-hour shifts and then have two or three days off. When caregivers request time off/are on vacation, shift substitutions are often given haphazardly, with little consideration given to which caregiver works with which children. Because of these inconsistencies, while “only” 9 to 12 caregivers may be assigned to a single ward per week, the net effect of all of these practices can mean that a child is exposed to 60 to 100 different caregivers during the first 19+ months of life – and no caregiver today whom the child saw yesterday or will see tomorrow.”9

In other cases, caregivers are underqualified to work with children who have faced such difficult or traumatic experiences, so the children suffer because the staff is not well equipped to address their psychological or emotional needs. Even when they are better-trained and more qualified, caregivers often take care of 10-20 children each and have to follow a rigid schedule to make sure that each child is fed, changed, and bathed. This routine hinders the caregivers from spending one-on-one time with each child to establish more than a surface-level relationship.

When children’s needs are not met at an early age because caregivers are overworked or unavailable, they do not establish the ability to rely on an attachment figure to meet their basic physiological needs, let alone their emotional needs. Children need to be invested in at a young age on a personal level. They need someone to answer their cries and care for them on a deeper level. When the goal of a child being in an institution is adoption, the goal of institutional caregivers and other influential adults in their lives should be to establish healthy and secure attachment habits for these children to assist them in transitioning into their permanent families.

Orphanage Voluntourism

Orphanage voluntourism has become a huge trend over the past several years. People want to be “socially responsible,” but even their most innocent and well-intentioned efforts can end up hurting the people they aim to help. Orphanage voluntourism can be defined as “a spectrum of activities related to the support of orphanages and children’s homes by individuals who are primarily or were initially tourists on vacation. In most cases orphanage tourism involves a tourist volunteer who wishes to include an element of social work-oriented volunteering in their vacation or travels and who chooses to do this by volunteering their time – sometimes coupled with financial or material support – to an orphanage.”10

For anyone who has participated in any sort of orphan care at an orphanage, it can be difficult to hear that such short-term assistance it might have its unintended harmful effects as well. However, if the goal of orphan outreach volunteering is to help solve the orphan crisis at hand, then best practice should avoid creating any additional attachment difficulties for the children residing in orphanages. When tourists visit orphanages, often “very few...are properly trained to interact with vulnerable or traumatized children, and their brief encounters with orphans can foster attachments that lead to disappointment on the part of the children when the volunteers leave.”11 Those who do choose to participate in such trips must be mindful of these issues and perhaps avoid investing too much time or attention in one particular child – instead they should invest in the group as a whole, serving, helping, and caring for all the children but not singling out one or another. If institutions do still require the assistance of volunteers, whether long-term or short-term, the volunteers must be equipped to deal with the trauma institutionalized children often face and knowledgeable in advance about attachment theory and the damage that can be done.

When Foster Care Isn’t An Option

Foster care is not currently an option in every country where children live outside family care, and even when it is seen as an ideal model, it may take time to put systems in place to fully integrate that model. Some countries will take time to build up the infrastructure to implement a foster care model, or it could be that within the country itself, foster care just is not seen as viable at the time. For example, in some settings it may be difficult finding families with the financial assets and desire to foster or adopt children; in others, cultural or religious bias against the practice of adopting or raising a non-biological child is a factor. Everywhere there is more frequent willingness to adopt young and healthy children, thus leaving older children or children with special needs lacking permanency.12

At this time, while “efforts are being made in many countries to care for children without permanent parents in family environments…it is not likely that transitions to family alternatives will be completed in all countries in the near future.”13 Institutions will probably continue to exist for the indefinite future, and there are ongoing efforts to improve the quality of care within these institutions – but much work remains. As a short-term response, implementing practices that more closely mimic family care within institutions may help diminish some of the negative impact of institutional care.

Family care is the best option for children anywhere. In a study on changes in wellbeing of orphaned and separated children placed in family care, Whetten asserted her belief in the importance of “[focusing] on improving the quality of caregiving in family settings and group homes, the well-being of caregivers and improving communities.”14 What does this look like in institutions, though, when in-home family care is not possible? Within institutions, family care models can be formed to help children establish consistent attachment relationships with a more permanent caregiver and other children. In these models, children are placed in quasi-family groups with consistent caregivers and other children varying in age, unlike most institutions where children are grouped by age and switch caregivers all too frequently. Caregivers are taught behaviors that are reminiscent of being a part of a family instead of the usual “dispassionate perfunctory care” that is the norm.15 Under these conditions, children can have more normalized development and have the opportunity to establish secure attachments with their consistent caregiver and the other children in their quasi-family unit.

Changing this in a large number of institutions worldwide will not happen quickly, or possibly at all. It would mean completely changing the culture within. To achieve this, caregivers would need to be trained to care for the children like they would care for their own – having “more warm, caring, sensitive, and contingently responsive interactions” both during “routine caregiving activities” and “free play.”16 To create the family groups, data collection could be done within the orphanages’ different wards to be able to place children in smaller groups that are a mix of different ages and needs.17 This would simulate being in a family, where there are children of different ages who are able to learn from each other – especially the young children looking up to the older ones.

The Big Picture

All children that are adopted have experienced loss to some extent. Once the adoption process is complete and children are united with their permanent families, the bonding period can begin. The attachment patterns that were established during early childhood then come to the forefront. More often than not, children are resilient. They are often able to work against the hardships that they have experienced in their early years and establish healthy, secure relationships with their families and friends around them. But children who were given the opportunity to establish secure and consistent attachments early on in their lives will likely find it easier to attach to their adoptive families. While family-based care models and foster care programs cannot yet be established on a broad scale in every country where children are waiting for adoption, it is still important to keep these care models in mind and strive to place an increasing number of children in the kind of nurturing, stable family-based care that will aid them in attaching within their permanent families should they be adopted.

Appendix: Steps to Foster Successful Attachment

  1. Understand Attachment: Educate adoption agency staff, adoptive parents, and child caretakers about attachment and its importance.
  2. Think Family: How can caretaking models be designed to mimic permanent family care?
    1. Foster Care: Provide true family settings for children’s temporary care until they can transition to permanent adoptive families
    2. When institutional care must be the option, try and limit the number of rotating caretakers and, whenever possible, provide consistent, educated caregivers.
    3. Create “family-style” institutions, with reasonable-sized groups of children for caretakers to manage; diversify the ages and needs of children in the group, just as a typical family might have children of multiple ages.
    4. Educate about voluntourism: When volunteers are engaged, use them whenever possible for non-caretaker roles, or make an effort to serve all children equally. When volunteers do interact with the children, include the permanent caretakers on-site, and ensure that all have basic education on attachment and how to appropriately engage with children who have experienced trauma.
  3. Limit Trauma in Transitions:
    1. During the Adoption Process - As much as possible, prospective adoptive parents should engage in attachment and getting to know you activities. Visit, send photos and letters, communicate via video or Skype if possible, and continue to express your ongoing commitment to the child.
    2. Before Traveling - When the child transitions to his or her permanent family, manage this carefully. Visit and interact with the child in the presence of the caretakers, and, when possible, spend time allowing the child to get more comfortable before traveling home.
    3. Stay Connected - Whenever possible, allow previous caretakers to stay connected to the child through letters, photos, online communication, or even visits as appropriate.


  1. Weitzman, C., & Albers, L. (n.d.). Long-Term Developmental, Behavioral, and Attachment Outcomes After International Adoption. Pediatric Clinics of North America, 1395-1419. Page 1406.
  2. Ibid. Page 1406.
  3. Ibid. Page 1407.
  4. Jinariu, M., Scott, S., Reimer, K., Sickel, A., Hopkins, K., Shore, K., & Butler-Angaga, B. (n.d.). Factors Leading to Secure Attachment in Children Adopted From Foster Care. PsycEXTRA Dataset. Pp. 6-7.
  5. Ibid. Page 44.
  6. Cole, S. (n.d.). Infants in foster care: Relational and environmental factors affecting attachment. Journal of Reproductive and Infant Psychology, 43-61. Page 56
  7. Jinariu, M., Scott, S., Reimer, K., Sickel, A., Hopkins, K., Shore, K., & Butler-Angaga, B. (n.d.). Factors Leading to Secure Attachment in Children Adopted From Foster Care. PsycEXTRA Dataset.
  8. Tucker, V. (2015, July 15). Foster Care Program LWB [E-mail interview].
  9. Groark, C., & Mccall, R. (2011). Implementing changes in institutions to improve young children's development. Infant Mental Health Journal Infant Ment. Health J., 509-525. Page 510
  10. Punaks, M., & Feit, K. (2014). The Paradox of Orphanage Volunteering. Page 14
  11. Baran, M. (2013). Rethinking voluntourism: Travel Weekly. Retrieved July 15, 2015.
  12. Groark, C., & Mccall, R. (2011). Implementing changes in institutions to improve young children's development. Infant Mental Health Journal Infant Ment. Health J., 509-525.
  13. Ibid.
  14. Hamilton, K. (2014). Orphaned Children Do Just As Well in Institutions. Retrieved July 15, 2015.
  15. Groark, C., & Mccall, R. (2011). Implementing changes in institutions to improve young children's development. Infant Mental Health Journal Infant Ment. Health J., 509-525.
  16. Ibid.
  17. Ibid.

Full List

Jinariu, M., Scott, S., Reimer, K., Sickel, A., Hopkins, K., Shore, K., & Butler-Angaga, B. (n.d.). Factors Leading to Secure Attachment in Children Adopted From Foster Care. PsycEXTRA Dataset.

Weitzman, C., & Albers, L. (n.d.). Long-Term Developmental, Behavioral, and Attachment Outcomes After International Adoption. Pediatric Clinics of North America, 1395-1419.

Groark, C., & Mccall, R. (2011). Implementing changes in institutions to improve young children's development. Infant Mental Health Journal Infant Ment. Health J., 509-525.

Whetten, K., Ostermann, J., Pence, B., Whetten, R., Messer, L., Ariely, S., . . . Thielman, N. (2014). Three-Year Change in the Wellbeing of Orphaned and Separated Children in Institutional and Family-Based Care Settings in Five Low- and Middle-Income Countries. PLoS ONE.

Center on the Developing Child at Harvard University. (2012). The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain: Working Paper 12. Retrieved online at