Wednesday 18 April 2007

Richard Bowlby - Stress in Daycare

April 2007

EXECUTIVE SUMMARY. Babies and toddlers in daycare can avoid stress and anxiety if they have a secondary attachment figure who always looks after them.

In any situation where they are separated from their parents, babies and toddlers younger than 30 months feel safe only when they are with someone else with whom they have an affectionate attachment bond. This paper will focus on the stress of separation experienced by babies and toddlers in non-parental day-care, who, for any reason, do not manage to develop or maintain a long-term secondary attachment bond to one person who cares for them.
  • This paper examines the importance of attachment theory for understanding the provision of daycare, and examines why some babies and toddlers acquire a psychological risk-factor that can affect their future mental health.
  • It discusses the environment needed for the emotional wellbeing of babies and toddlers younger than 30 months during non-parental daycare.
  • It raises social policy concerns about the provision of mental health services, education support, and control of antisocial behaviour.
  • It outlines recommendations within the Sure Start programme for the provision of non-parental daycare for babies and toddlers younger than 30 months.
As recently as a generation ago, non-parental childcare for babies and toddlers was usually provided by people the parent knew really well such as granny, father, neighbour, nanny or childminder. This close relationship may be highly significant because there would have been an expectation and a high probability that the baby would form a secondary attachment bond to that person, especially if the daycare was introduced gradually over several weeks.

Many researchers, academics and clinicians are now worried about the psychological effect on babies and toddlers younger than 30 months who do not manage to develop a lasting secondary attachment bond to one person who always cares for them during non-parental daycare. If neither their primary nor a secondary attachment figure is accessible, most babies and toddlers will usually protest by crying and searching for an attachment figure, sometimes for an hour or more, (although some appear to manage better).

Although the most well known response to fear is fight or flight, these aggressive responses are impractical for babies and toddlers and they tend to use a different response - dissociation or ‘psychological flight’ which can be seen in the ‘freeze and surrender’ response. There’s a wide range of dissociative behaviours that babies and toddlers use when they’re unable to reach an attachment figure: some behave as if they are unaffected by the experience, whilst others keep active but are rather subdued or withdrawn, and some quietly occupy themselves alone and are undemanding and seen as ‘easy children’. Others are overly compliant or obedient and unusually co-operative, and if they become even more distressed some may rock themselves or become frozen or ‘still’.

Although the stress of repeated separations may show in subtle behaviour changes, most parents and carers either don’t associate these changes with the daycare experience, or don’t realise that it could become a significant risk-factor that increases the likelihood of children developing emotional problems in the future. The combined effect of having three or more significant risk-factors can be overwhelming and lead to child and adolescent mental health problems, educational difficulties and antisocial behaviours.

Sure Start has an excellent model for self-employed childminders who work from home; this model increases the likelihood of babies and toddlers developing a long term secondary attachment bond to the childminder, especially if care is gradually introduced over several weeks. However, when it comes to childcare in Children’s Centres where babies and toddlers are in day-nurseries, Sure Start has a very different model that has a reduced likelihood of babies developing an attachment bond. Day-nurseries rarely provide continuity of personalised caregiving throughout the pre-school years, and therefore provide little opportunity for developing and sustaining a long term secondary attachment bond to an individual carer, even where there is a Key-Person policy.

NOTE During the first 9 months, babies need sufficient time and attention from their mother/primary attachment figure in order to develop as secure a primary attachment as possible before starting any form of non-parental day-care. This is supported in the UK by the recent introduction of statutory paid maternity leave for the first 9 months.

  • The Sure Start childminder model is more likely to be able to provide babies older than 9 months with appropriate child-care, and Children’s Centres should provide childminders with professional supervision and support.
  • The Sure Start day-nursery model for Children’s Centres is much less likely to be able to provide appropriate child-care for babies and toddlers younger than 30 months.
  • The Sure Start Children’s Centres should provide social, emotional and medical support services for mothers and carers of babies and toddlers, and provide high quality pre-school nursery education and appropriate non-parental daycare for children older than about 30 - 36 months.
With so much focus on cognitive educational attainment, there’s a grave danger that the emotional wellbeing of babies and toddlers younger than 30 months is being overlooked. To establish positive emotional health during this most sensitive period of brain development, it is absolutely essential that continuity of personalised caregiving is available to babies and toddlers at all times, either from their primary attachment figure or from a long-term secondary attachment figure.

Contact. Sir Richard Bowlby Bt. Boundary House, Wyldes Close, London NW11 7JB,

DAYCARE LECTURE NOTES Richard Bowlby 2007.

Babies and toddlers in non-parental daycare can avoid stress and anxiety if they develop a lasting secondary attachment bond with one carer who is consistently accessible to them.

Throughout human evolution, mothers have been helped to care for their young by members of the extended family. Some of these will have known the baby since birth and become secondary attachment figures, and their motivation to provide care would have come from shared attachment bonds. Then, the carer and baby would have had ready access to mother for feeding on demand and co-sleeping at night, and would usually have been within sight or earshot of her.

Over the past 50 years, child development researchers have gained a profound understanding of the social and emotional needs of children and the importance of forming stable and loving family bonds, and during the past 20 years there’s been a vast array of new technology that’s given neuroscientists the ability to discover how these emotional experiences affect the infant’s developing brain. In this talk I want to examine the need of babies and toddlers to make secondary attachment bonds to their carers during non-parental child-care, and to look at the consequences for their emotional development if for any reason they are not able to do so. I’m not going to address the needs of children older than 36 months.

I shall examine the likelihood of babies and toddlers having the opportunity to develop and maintain a secondary attachment bond to one committed carer within the Sure Start scheme both for registered childminders and for carers in day-nurseries. Although achieving this may seem unrealistic and even unnecessary, I’m increasingly convinced that this is a fundamental necessity for all babies and toddlers if they are to tolerate daily separations from their parents. In this paper I am presenting my own views which are based mostly on research findings and attachment theory, and partly on the opinions and circumstantial evidence provided by many professionals working in the field, and also on my personal observations and experiences - comments and contributions are welcomed!

I was born in 1941 and I’m married and have two children and five grandchildren, and I worked as a scientific photographer in medical research until I retired in 1999. My father, John Bowlby, was a scientist, and his theory of attachment was first outlined in 1958 and has now emerged as one of the world’s largest fields of academic research into children’s emotional wellbeing. Most of science is based on the probability of a theory being correct and attachment theory has been attacked, praised and tested from so many angles that there’s a high probability that it is correct.

As humans, each of us is the sum of our experiences interacting with our genetic inheritance. Our capacity to make intimate attachment bonds and our ability to form social relationships is rooted in the gene/environment interactions of our early childhood experiences. But we are not all born with the same genetic makeup, neither do we all have the same experiences in life. Some are born more physically or mentally robust than most, whilst others are more fragile than most; however, the majority are born with fairly similar propensities to respond to experiences in fairly predictable ways. To develop into young adults who are emotionally robust and socially competent, babies and toddlers need prodigious amounts of time and sensitive attention from trusted attachment figures. But parents nowadays have to make the choice between giving their babies and toddlers these experiences on the one hand, and on the other hand giving enough time & attention to paid work for adequate family income.

In the 1950’s, observational research studies exposed the level of psychological trauma experienced by babies, toddlers and young children who stayed in hospital or residential nursery for ten days or more with only brief visits from a parent. These toddlers were physically well cared for but they were helpless to reach their parents and lost hope of being ‘rescued’ by them. The sense of danger and the fear that separation induced in these children was such that many grew up feeling the impact of this early experience throughout their lives. The research studies of the 1950’s eventually lead to the present policies of paediatric wards providing overnight accommodation for parents, and for babies and toddlers in extended non-parental care being fostered or adopted rather than living in institutions.

Now researchers are worried that similar, though less traumatic and much less easily detected developmental problems may be experienced by some babies and toddlers who spend long periods in non-parental daycare each weekday. These problem seems to be more common for babies and toddlers aged between 6 months and 30 months, and when a baby is cared for by unfamiliar people, instead of by one who is well known and trusted. There has been a longstanding debate about whether these experiences have any effect on babies and toddlers, and if they do, whether the effects will last or disappear, or whether they’ll reappear later as a ‘sleeper effect’. But there is now evidence showing a small increase in negative behaviour that endures into later childhood that’s linked to children who were in centre based day-nurseries when they were babies and toddlers - the unintended by-product of a very convenient practice.

I have a growing conviction (shared by many health care professionals), that these negative behaviours most commonly occur in babies and toddlers who experience periods of daily separation from all their trusted attachment figures, and that this is more likely to happen in centre-based day-nurseries than in other forms of non-parental childcare. My concern is that these negative behaviours may be just the visible tip of a more pervasive underlying psychological problem that could influence children’s future emotional resilience and mental wellbeing. We urgently need research to clarify this situation, but research in this field is very contentious, extremely complex, difficult to get financed and usually takes many years to produce results, and even then there are often more questions than answers!

In attachment theory, the term primary attachment figure refers to the person with whom a child develops their main lifelong emotional bond, and whom they most want to be comforted by when they are frightened or hurt - usually but not necessarily their birth mother.
The term secondary attachment figure refers to the few special people in a child’s life with whom they have developed a close subsidiary or secondary attachment bond, such as siblings, grandparents, nannies, childminders and especially fathers who have their own unique bond.
Having three or more such people will usually increase children’s resilience and act as a protective factor throughout childhood. These are the people who can provide babies and toddlers with comfort and security in the absence of a primary attachment figure, and act as a secure base and haven of safety.

Secure attachment means having a predictable, safe and affectionate bond with an attachment figure (either the primary or a secondary). Securely attached babies and toddlers are not usually affected by a few hours of separation from their primary attachment figure if they’re being looked after by a person with whom they have developed a secure secondary attachment bond. When these carers are consistent, sensitive and responsive they can benefit toddlers’ social and cognitive development and provide support to families.

Insecure attachment means having a less predictable bond with an attachment figure (either primary or secondary). By itself insecure attachment is very difficult to identify unless the Strange Situation Procedure is employed. Insecure attachment is found in approximately 40% of toddlers in the UK and USA, and is acknowledged as a risk factor that often contributes to the mental health problems of children and adults. Insecure attachment can be classified as either avoidant, ambivalent or disorganised, and such babies and toddlers are less emotionally robust and more vulnerable to separation distress than securely attached toddlers.
Once established, and in the absence of any major life events, there is a tendency for the quality of a child’s primary attachment bond to become their model for making future attachment relationships throughout their life.
Most babies younger than about 6 months have not fully developed the capacity to form attachments and do not usually sense danger when ‘cared for by a stranger’. By 9 months the babies’ primary attachment bond is developing and their ability to differentiate between familiar people and unfamiliar strangers is usually well advanced, and by 12 to 14 months their bond to their primary attachment figure is usually well established. This is the age when the Strange Situation Procedure can be used to stress a toddler and assess the quality of their attachment bond. Mother and toddler are put in an unfamiliar room with plenty of toys, a stranger joins them and a few minutes later mother leaves the room and the toddler is alone with the stranger in a strange place. At this age, toddlers instinctively sense this strange situation as being dangerous and they become frightened even when the stranger tries to comfort them. Then mother returns after a minute or two and the stranger leaves. What demonstrates the quality of the attachment bond between toddler and mother, is the mother’s ability to comfort and reassure the toddler, and the toddler’s ability to accept comfort and return to confident and productive play.

There is a tendency for parents to form a similar quality of attachment with their babies as they had with their own parent (primary attachment figure) when they were babies - it comes naturally to parent the way we were parented, it does not come naturally to do it differently!

I’d like this opportunity to clarify a few points.
When searching for the origins of children’s emotional problems, there’s a great temptation to assume that the discovery of a link between a cause and an effect, is proof of a genuine correlation.
A problem faced by many researchers is sample bias. For example higher quality daycare providers are more likely to take part in studies of child development than are lower quality, or unregistered providers.
I avoid using the term ‘separation anxiety’, because it’s now being used to describe an entire spectrum of childhood behaviours ranging from mild protest when a baby tries to follow an attachment figure into another room, right through to the traumatic effects of months in institutional care.
Another point is that because attachment seeking is a child’s natural response to separation, that the separation is therefore not traumatic - its natural!
And finally, some parents have the mistaken belief that their 6 month old baby has become over-dependent on them, and that this can be ‘corrected’ by leaving the baby in a supervised group without having one of their attachment figures present.

Neuroscientists have observed that important structures in babies’ brains are shaped by their emotional experiences, and that the most positive and the most negative impacts on the brain are the result of social and emotional relationships (enduring or fragmented), especially with their primary attachment figure (usually their mother). The physical structure of babies’ brains is affected by the hormones that are generated within attachment relationships during the first two years whilst their brains are doubling in size.

In babies and toddlers younger than about 30 months, the right hemisphere of the brain develops more rapidly and exerts more control over them than does the left side of their brain. The right side develops the intuitive and emotional skills which are needed for relationships, and for the empathic understanding of another person’s feelings. Babies learn these unconscious skills by experiencing sensitive and responsive care over and over again, and the quality of relationships and the feelings they generate day after day can have a significant influence on the structure of the developing brain. These early experiences cannot be consciously recalled later on because they occur during the pre-verbal phase of brain development, but the enduring feelings and expectations will play an important part in forming their personality throughout childhood.

By about 33 months, toddlers’ brains begin to undergo a very significant change. The growth spurt of the right side of the brain has slowed down and the sensitive period for developing social and emotional intelligence makes way for a growth spurt on the left side instead. By about 36 months the left side of the brain becomes dominant, and this promotes the development of complex speech and the ability to remember past events and anticipate future ones. High quality pre-school nursery education (which is different from daycare) helps most children older than 36 months to develop their cognitive skills and social independence, but researchers have consistently found no such benefits for babies and toddlers younger than 24 months. For these reasons, toddlers aged between 24 and 36 months need very careful assessment of their individual capacity to cope with the stress of separation, and the average age of 30 months must be used as a guide only.

The risk-factors that contribute to emotional disturbance in children vary greatly in their severity. Poverty is a well known risk-factor which tends to make the impact of all other risk factors even greater. Serious risk factors include family breakdown, having a parent who was raised in care, having parents who are chronically neglectful, have a drug or alcohol problem, are abusive, violent or criminal. Other childhood risk-factors that are not as serious include parental depression, young unsupported parenthood, and lack of parenting skills. The adverse effect on the child will be mediated by their genetic predisposition to different experiences, and by the particular combination of experiences. Complex traumatic events of an interpersonal nature which start at a very young age and last several years, can have a pervasive effect on a child’s brain and lead to developmental trauma disorder.

Toddlers who are insecurely attached to their primary attachment figure have a risk factor. Toddlers who are securely attached may have a risk-factor if they are in non-parental daycare without an attachment figure. These two risk factors are difficult to detect individually, but if toddlers are both insecurely attached and have no access to an attachment figure during daycare, they experience two risk factors which acting together are likely to be more easily noticed.
An increasingly common risk-factor is parental separation. This can usually be tolerated by securely attached children if they have no other risk factors, but if insecure attachment is added to daycare without an attachment figure, and then there is family breakdown as well, the three risk factors acting together can overwhelm children and increase their risk of developing social and emotional problems in the future. These can include aggressive and disruptive behaviour, attention deficit, low academic achievement, truancy, drug and alcohol abuse, self harm, eating disorders, poor empathic skills, low self esteem, unhappiness, depression and negative expectation of life. All of these can exacerbate family conflicts and strained parental relationships.

NOTE There is a tendency to focus on the most recent or obvious risk-factor in a child’s history and attribute a disproportionate significance to it. Children’s capacity to tolerate one or two modest risk factors will often mean the risks go undetected, and the most recent experience is then singled out as the sole cause.

In the normal course of everyday life, babies, toddlers, children and adults all thrive on moderate and predictable amounts of controllable stress that’s appropriate for their age and development. These experiences produce normal levels of cortisol which is needed by the body for healthy functioning, and levels of cortisol will rise and fall throughout the day depending on many different physiological and psychological factors. However, babies and toddlers have extremely fragile brains that are developing very rapidly, and some researchers are growing very concerned about babies and toddlers whose levels of cortisol are elevated all day. They worry that because babies’ brains develop in response to the neurochemicals in their body, their brains may become adapted to chronically high levels of cortisol, and this may be affecting their ability to control their emotions and behaviour as they grow up.
Attachment theory predicts that babies and toddlers will sense an increased level of danger when they are unable to access their primary or a well known secondary attachment figure. This triggers an alarm reaction that activates their attachment seeking response which is heightened if they are in unfamiliar surroundings. The theory also predicts that at this young age the attachment seeking responses will not be adequately satisfied by a relatively unknown person.

Babies and toddlers between the age of 6 and 30 months tend to live in the present, and if they do not receive sensory evidence (sight, sound, touch, smell or taste) that any of their familiar attachment figures are available, they have an instinctive sense of danger which increases by the minute. This sense of danger raises their levels of cortisol (the fight, flight or freeze hormone) and induces a degree of distress - but what are the defences that babies and toddlers have available to cope with this form of distress?

Trauma theory predicts that children who sense danger will experience distress and escalating arousal, and will display increasing levels of ‘survival’ behaviour. The arousal continuum starts with being calm, then showing increased levels of vigilance, progressing through anxiety and distress, to fear, with terror being the most extreme. If adults or children sense a life threatening danger - real or perceived - from which they are unable to defend themselves and from which they have no hope of being rescued, they will experience psychological trauma - the degree depending on their level of distress. When unable to access any well known and trusted attachment figure, babies and toddlers usually (but not always) protest and become highly aroused, and if their ‘flight towards’ an attachment figure is barred, they may try to ‘fight’ by struggling and crying to varying degrees - some may cry only briefly and others more-so, but some become visibly distressed and scream long and loud.

Although the best known response to fear is the aggressive fight or active flight behaviour, these responses are impractical for babies and toddlers and they tend to use dissociation as ‘psychological flight’. The level of dissociation will depend on the intensity and duration of the real or perceived threat, and this can temporarily de-activate babies’ attachment seeking response behaviour. There is a wide range of instinctive and learned dissociative behaviours that babies and toddlers adopt when they are unable to reach an attachment figure: some appear unaffected by the experience of separation, and others may be over boisterous or aggressive, some continue to be active but are rather subdued or withdrawn, and some quietly occupy themselves alone and appear to be undemanding and ‘easy children’, whilst others may be overly compliant or obedient and unusually co-operative. At the extreme end of the dissociative spectrum is the ‘freeze and surrender’ response of blanking or stilling. Babies’ instinct to de-activate their attachment seeking response under stress in the absence of an attachment figure probably originated as an emergency measure to reduce the risk of being detected in the natural environment of evolution.

It’s important to distinguish between well focussed and secure exploratory play, and dissociative coping behaviours. The chronic stress of repeated separations can show as subtle behaviour and mood changes, but these are easily misunderstood and are often interpreted as babies and toddlers settling in and accepting their new surroundings. However their saliva cortisol levels are elevated, and their behaviour is often not the same as it is when they’re at home.

There are many different daycare arrangements for babies and toddlers in the U.K., and a wide variety of people providing them. The arrangements provide varying degrees of continuity of care, and the carers provide varying degrees of secure or insecure attachment, but some situations are more likely than others to provide a stable attachment between a baby and carer. The carers will have different temperaments, experiences and training, and the babies and toddlers will be of different ages, sexes, temperaments and birth orders, and have a range of secure or insecure attachment to their primary attachment figure at home.

A well staffed day-nursery in a modern Children’s Centre is many parents’ choice of daycare. However, many babies and toddlers have been found to have significantly elevated levels of cortisol in their saliva samples whilst they are attending centre based daycare without an attachment figure, and normal cortisol levels whilst their parents are present during the initial settling in period of a few weeks. This observation is consistent with separation from parents being stressful to a baby in the absence of a secondary attachment figure. Stress from loud noises, minor accidents, conflicts and aggressive play are other causes of elevated cortisol, but this is not straight forward as some severely traumatised babies and toddlers have developed abnormally low levels of cortisol.

When babies and toddlers are eventually reunited with their primary attachment figure and receive enough time and sensitive attention, they are usually able to be sufficiently comforted that their cortisol levels return to normal before bedtime. In terms of attachment theory, their attachment seeking behaviour was activated as they entered daycare, de-activated during daycare and then re-activated when they got home. Without any additional risk factors many babies and toddlers appear to tolerate this daily cycle without noticeable long term effects. However, there are some babies and toddlers who are unable to be sufficiently comforted when they return home and their cortisol levels remain elevated and do not return to normal before bedtime. Their attachment seeking behaviour remains de-activated, instead of being re-activated and in the morning their cortisol levels are still elevated.

In my view, many babies and toddlers are using dissociation as a mechanism to de-activate their attachment seeking behaviour when they become overwhelmed by the stress of daily separation from their primary attachment figure in the absence of a secondary one. I think the regular use of this emergency survival mechanism is likely to be a risk factor for many babies and toddlers that increases their vulnerability to the impact of any additional risk factors if they experience them in the future.

A situation that can be a serious risk-factor, is if a baby develops a primary attachment bond to a carer - someone like a live-in nanny - instead of to their mother, and then when the carer leaves the family the baby’s primary bond to her gets broken. A similar problem can arise when a grandmother raises the baby of her teenage daughter who then removes the child from the grandmother after a few years to start a new family. This form of loss can adversely affect children of any age, but if it happens during the preverbal phase of development they will be unaware of the origin of the pervasive anxiety they may experience throughout their lives. Many people do not understand the reason why a child is so distressed, and may deny the real explanation which can compound the child’s anxiety even further.

The chances of a baby becoming primarily attached to a carer are more likely:-
  • when the carer starts looking after the baby soon after birth
  • when the carer spends more time with the baby than the parent
  • when the carer is living in the baby’s family home
  • when the carer comforts the baby at night
  • when the carer is unclear about relationship boundaries.
The occasional loss of a secondary attachment figure need not be too distressing to a toddler if it’s sensitively handled by the primary attachment figure. But some parents keep swapping carers to prevent a bond developing, or choose day-nursery because the number of carers will stop babies getting too close to one of them. Regular swapping of carers can be a risk factor.

Some forms of group daycare do not lend themselves to babies and toddlers developing a lasting secondary attachment bond to one carer because the difficulty of maintaining continuity of personalised care-giving is too great. There may be too many babies or toddlers per carer, or more than one carer providing for a baby’s needs each day, or carers who may not have the time or inclination to form an attachment, or who are young and may not intend to stay very long.

Sometimes babies or toddlers do form attachments but policy may require babies to move to new groupings, or carers to be moved to other duties. Some carers may only work part time or be students on placement who only stay a few weeks, and sometimes agency staff have to cover for carers on sick leave. If any of these happen too frequently the pain of repeated separation or loss can make babies and toddlers reluctant to form a new secondary attachment bond to another carer, especially if either the baby or the carer tends towards insecure-avoidant attachments.

A few babies and toddlers may easily make friends with adults and may be reasonably comforted by a wider circle of carers, but most babies and toddlers need access to a secondary attachment figure to meet their emotional needs during non-parental daycare. Some babies and toddlers who are more sensitive than most, cannot manage separation from their primary attachment figure and cannot take comfort from a secondary attachment figure.

NOTE Parents may want to encourage their babies’ and toddlers’ cognitive skills, and be tempted to start pushing their education very young, focusing rewards mainly on achievements. Toddlers who feel they have to earn approval may become diligent students but emotionally rather withdrawn, and others, especially boys, who find personal relationships difficult may become preoccupied with various forms of solitary home-entertainment.

In order to develop and maintain a secondary attachment bond between a baby and a carer, it’s necessary that the carer provides continuity of personalised care for several years. But even then there is no certainty that a bond will develop. For a bond to develop between them, the carer must be willing to make an emotional commitment to the baby. Even the most sensitive daycare with a secondary attachment figure is likely to be more stressful than care from the primary attachment figure, but it does not seem to constitute a significant long-term risk factor for either secure or insecure children.

A model for attachment-based daycare is a family-type grouping which allows a carer to provide age appropriate care for each child.
The sort of features that distinguish attachment-based daycare are:-
  • that babies are not accepted until they’re about 9 months old, by which time they have formed a primary attachment bond to the person who’s raising them - usually but not necessarily the birth mother. Nine months statutory maternity pay has just been introduced in the UK.
  • that carers actively encourage babies and toddlers to form secondary attachment bonds to them, and this is sanctioned by the parents
  • that babies and toddlers are accompanied by their primary attachment figure for the first few weeks of daycare whilst the baby makes friends with their new carer - the first stage of developing a secondary attachment bond
  • that by introducing a few minutes of separation and gradually increasing the time, the baby realises that they can take comfort from their carer and feel secure, keeping cortisol levels as low as possible
  • that the duration of care each day is kept short for babies whilst their secondary attachment bond is developing
  • that the babies and toddlers are in part time daycare until they’re 18 months old
  • that carers look after no more than three babies or toddlers well spaced in age: one aged 9 to 18 months, one between 18 and 36 months, and one child older than 36 months
  • that carers have sufficient energy, and are trained and supported to meet the physical, cognitive and emotional demands of the babies, toddlers and young children in their care
  • that babies’ and toddlers’ secondary attachment needs are always met, maintained and monitored.
  • that carers’ emotional attachment to the children they care for is sensitively supported and monitored
  • that parents are supported in maintaining their child’s primary attachment bond to them.
The original Sure Start projects in the UK provided very little daycare and focused mainly on the social and emotional needs of mothers and young children, and many of these valuable services still survive. However, whilst retaining the original name, there’s been a very significant change of purpose as Sure Start has gradually moved towards the administration of daycare.

The two models of non-parental daycare covered by Sure Start in 2007 are for registered childminders and for day-nurseries in Children’s Centres. In the Sure Start document ‘About childminders, Why choose a childminder?’ the first two points are that childminders can: (1) “Provide consistent one-to-one care, tailored to the individual needs of a child. (2) Form a stable ongoing relationship with the child, continuing from when they are a baby through to when they need care around schooling.” Then in another Sure Start document ‘Thinking about childminding?’ in the section ‘How many children could I look after?’ it says “You can look after up to six children under eight, including your own. No more than three of the six children should be under five and normally no more than one child can be under one”.

The childminder model supports family groups of three children under 5, and is sensitive to the needs of babies under 1 to have individual time and attention. The childminder model actively promotes continuity of personalised caregiving which facilitates the development of a long-term secondary attachment between a child and childminder throughout the pre-school years. The relationship is supported through the financial contract between the parents and the self-employed childminder to care for their child in the childminders home.

By comparison the Sure Start document ‘Full day care’ says the minimum ratios of staff to children in Children’s Centres are, 1:3 children under two years, 1:4 children aged 2 years, 1:8 children aged 3-7 years. In the phase 2 (2006-08) document ‘A Sure Start Children’s Centre for every community’, Chapter 3, it says, “These following services must [sic] be offered in the 30% most disadvantaged areas (Super Output Areas): Early years provision (1) Integrated early learning and childcare for babies and children until they are five years old. (2) Childcare suitable for working parents/carers for a minimum of 5 days a week, 48 weeks a year, 10 hours a day.” - end of quote. That’s a minimum provision of 50 hours per week, with no minimum starting age and no maximum number of hours!

In order for the 30% of babies and toddlers who fall into the most disadvantaged category to learn that relationships can be enduring, trustworthy and secure, they need to experience a positive model of a secure and enduring relationship. This is much more likely to happen with a childminder than in group daycare, even where there is a Key Person policy in nurseries.

My concerns are these:-
1) The Sure Start Children’s Centre model for day-nurseries does not specify the number of babies under 1 year old that a carer may look after. It specifies three children under 2, and therefore does not address the need of babies to have individual time and attention in order to develop a secondary attachment to one carer.

2) This model requires childcare to be available for a minimum of 50 hours per week in the 30% most disadvantaged areas, which will necessitate shift working and a change of carer and Key-Person for babies and toddlers who bridge two shifts.

3) This model requires carers each to care for a group of babies, toddlers and young children within a certain age range, and the children are likely to have a different carer when they are old enough to be moved into the next age-group.

4) Staff in this model are employed by the Children’s Centre and will be required to undertake duties as instructed by their employer, which may involve temporarily or permanently discontinuing the care of a child.

5) Many Children’s Centres have staff retention difficulties and high staff turnover. They may use agency staff for temporary cover, or have short stay students on work experience.

The Sure Start publications about childcare provision in Children’s Centres are sending out a strong message to parents that there is no lower age limit for babies to start in daycare, and that there is no upper limit for the duration of daycare each day or the total number of hours each week. Parents will reasonably assume that these officially sanctioned practices have been proved to be universally beneficial to the emotional and social development of their babies and toddlers.

Long periods without access to any attachment figure is probably a developmental risk factor that goes undetected at the time, but which leaves babies and toddlers more vulnerable to developing social and emotional problems in the future. In a society which encourages both parents (or single parents) of babies and toddlers to work outside the home, attachment-based daycare can play a crucial role in helping to balance work and family life without putting children’s emotional development and mental health at risk.

The long-term effects of inappropriate daycare on babies and toddlers is not immediately obvious, and with no ‘blood on the carpet’, and all Sure Start daycare being widely promoted as beneficial, there is no incentive for parents to start questioning specific aspects of daycare. The subject has become so highly charged and personal that there is no easy way to help worried parents understand the attachment needs of their babies and toddlers and make better-informed choices.

Parents concerned for the safety of their babies and toddlers are attracted by the level of security, staff qualifications and supervision offered by day-nurseries, but many of these day-nurseries cannot provide babies and toddlers with adequate continuity of personalised care-giving. Being unable to access an attachment figure during non-parental daycare can result in babies and toddlers experiencing stress and elevated cortisol levels, and my concern is that this may become even more widespread when the planned additional 2,500 day-nurseries in Sure Start Children’s Centres are opened by 2010

Many babies and toddlers receive a risk factor at home from insecure attachment and another risk factor from non-parental daycare where there is not a ‘good enough’ secondary attachment figure. These two risk factors have become normalised within the UK, but they can be potent contributors to future mental health problems if a further risk factor such as parental separation is encountered. The combination of these three common risk factors can result in the increased likelihood of behaviour difficulties and mental health problems in children and adolescents across all social groups.

There are individuals and organisations who expect to provide secondary attachments for the babies and toddlers in their care, and they have adopted practices from the models of both childminders and day-nurseries. These arrangements may have been established with theoretical understanding of the attachment needs of babies and toddlers, or have evolved over time with instinctive and empathic insight into their emotional needs.

Two models that I know of:-
  • The Soho model is a charity which accommodates a group of 7 or 8 self-employed child-carers working under the supervision of a co-ordinator at the Soho Family Centre. Each child-carer expects to form a lasting secondary attachment bond with each of the three children under 5 that she cares for, only one of whom is younger than 18 months, and she is paid directly by the parents to care for their baby or toddler (very similar to childminders).
  • The Richmond model is a charity that provides training and support to childminders, through their childminder co-ordinators plus an outreach worker who visits the childminders in their homes. The co-ordinators help organise childminder networks which reduce isolation and monitor the child / childminder attachments. The co-ordinators have links with Children’s Centres and organise childminder drop-ins, and events for new parents to meet local childminders.
Although I consider that babies and toddlers have a significantly greater chance of developing a long term secondary attachment to a Sure Start childminder than to a Sure Start carer in a day-nursery, there’s no guarantee of this. It’s essential that the carer expects the baby to develop a lasting attachment to them, and that the carer is prepared to reciprocate at an appropriately professional level - which is carefully monitored. It’s also vital that the babies’ primary attachment bond to their primary attachment figure is as secure as possible, and that it’s maintained throughout the period of non-parental child-care. This is especially important for those parents and babies who are most vulnerable.

  • The Sure Start childminder model. For babies older than 9 months whose parents need them in daycare, the childminder model has a reasonable probability of providing a long-term secondary attachment bond between a baby or toddler and a childminder.
  • The Sure Start day-nursery model in Children’s Centres. The day-nursery model does not have a reasonable probability of providing a long-term secondary attachment bond between a baby or toddler and a carer.
  • The Sure Start Children’s Centres should provide childminders with professional supervision and support facilities, with social, emotional and medical services for parents and carers of babies and toddlers. Children’s Centres should provide appropriate daycare for children older than 36 months, plus high quality pre-school nursery education.
With so much focus on cognitive educational attainment, there’s a grave danger that the emotional development of babies and toddlers will not be sufficient for them to take full advantage of their future educational opportunities. For positive emotional development during this most sensitive period of brain growth, I believe that it’s absolutely essential that continuity of personalised caregiving is available to babies and toddlers at all times, either from their primary attachment figure or from a trusted secondary attachment figure.

NOTE I have been a patron of The Soho Family Centre since 2003. The Centre has been providing attachment daycare since 1986, based on a model of having self-employed child-care staff working together in a co-operative group, in accommodation provided and managed by the Soho Family Centre.

Sir Richard Bowlby Bt.,
President, Centre for Child Mental Health.
Patron, Soho Family Centre.

Contact details Boundary House, Wyldes Close, London NW11 7JB U.K. Tel: 020 8458 8474. Int Tel +4420 8458 8474. Email,

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Separation and the Very Young, James and Joyce Robertson. 1989
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Sure Start - About childminders.
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Sure Start - National Evaluation of the Neighbourhood Nurseries Initiative: The Relationship between Quality and Children’s Behavioural Development. S. Mathers and K. Sylva Dept. of Educational Studies Oxford. DfES report SSU/2007/FR/022

Additional Reading.
Raising Babies: should under 3s go to nursery, Steve Biddulph 2006.
Why Love Matters: how affection shapes a baby’s brain. Sue Gerhardt, 2004. Buy here.
Social Intelligence, The New Science of Human Relationships. Daniel Goleman 2006
Who will look after my baby best? What About The Children

Copyright © 2007 by Richard Bowlby. This article may be downloaded, reproduced, and distributed without permission as long as each copy includes this notice. Permission must be obtained in order to reprint this article in a published work or in order to offer it for sale in any form.

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