Psychiatric Aspects of Placement and
Visitation of Children
Under Three Years of Age
Margaret P. Gean, M.D.
While working in our infant psychiatry program, I am frequently asked to evaluate children with regard to their bonding and attachment, developmental status, and the designation of a permanent primary caregiver. This last issue is especially complex because the best interests of the child, in addition to the fitness of the parents, must be considered by the courts in making a determination. In this article I examine the issue of visitation with biologic relatives who are not providing a child's primary care. Data were gathered by retrospective chart review. The response of young children to visitation and its impact on the attachment process are discussed.
My initial hypothesis was that children under three years of age were too young cognitively and affectively to tolerate frequent visits away from the primary caregiver, and that the attachment to the psychological parent (primary caregiver) was affected by disruptions occasioned by visits to other relatives. I postulated that symptoms during and after visits appeared initially as a reactive disturbance (Adjustment Disorder, DSM-III, see American Psychiatric Association ) and that severe disturbances reflected the onset of an attachment disorder.
A prevalent symptom following visits was increased attachment behavior to the primary caregiver. Sleep disturbances for several days, aggressive behavior, withdrawal, eating disturbances, and fussiness were reported. The severest problems included regressive behaviors, failure-to-thrive, chronic attachment disturbances, and developmental delays. The verbal child frequently expressed reluctance to go on the visit and had questions about the permanence of care in the foster home. In the initial phases of visitation, the children usually had several days of being symptom-free prior to the next visit. Ongoing regular visitation frequently resulted in symptoms being sustained for the entire period between visits.
Most visits were carried out to meet legal or parental needs. They were not matched to the young child's limited evocative memory or to the need for the presence of a primary caregiver in stressful circumstances. The effects of this emotional disruption on the overall attachment process and its consequences on the