Touch, physical and emotional. Abuse or neglect?

by Mar 22, 2016Abuse, Attachment1 comment

What is the place of touch, physical closeness, and indeed emotional closeness, in professional relationships these days?  In these post Saville days there seems to be a lot of confusion. Quite rightly people and organisations are wary of the risk of inappropriate touching and of child abuse, awareness of which is thankfully much higher.  Much of my clinical work is at the Portman clinic where we see many sex offenders, and we are all too aware of the serious dangers of ignoring these issues, the vital importance of Safeguarding and the need to ensure children are protected. However the counterpoint is an increasingly frightened and rule-bound culture which looks after professionals and institutions and puts their interests above the children in their care.

I am seeing many examples of professionals working with children becoming wary of any kind of closeness in case this is seen as unprofessional, or even abusive. I myself am increasingly cautious about seeing children for therapy in private rooms where there is a background of abuse, and with some children I have insisted on videotaping sessions. This is in great part for my own safety, and that of my institution with its risk management policies, at least as much as for the children’s benefit.

I often hear stories from professionals and colleagues about how such anxieties take away from the kind of real human contact that facilitates emotional safety and hence learning. This is especially the case for those working with younger children. One foster carer felt she could not give her 5 year old foster child a goodnight cuddle, or hold him when he was upset after an accident. While foster carers think of their role as professional, they also are playing the role of parent to some of the most needy children in society, and such fears can lead to behaviour which can seem callous.

I recently saw a distressed male nursery teacher whose headteacher called him into her office after 2 female workers had complained that he had a 3 year old on his lap. The 3 year old was in huge distress, sobbing plaintively and needing comfort. This was in plain view of all staff and children, there was nothing remotely untoward about it, and he did what any caring  ‘in loco parentis’ adult would hopefully do. Apparently the child was relieved, calmed down and in a short time was off playing again. This is what we hope to see in a secure attachment relationship, in  which children thrive.

Another nursery worker I consulted to left his job after being told that there can be no physical contact at all. He had returned to nursery teaching after 15 years abroad and was shocked anyway at the new regimes. The kind of ordinary attuned attention that is growth enhancing and which facilitates curiosity, interest and learning was being constantly undermined by processes of outcome monitoring and form-filling. He was despairing that he could not just empathically be with a child, facilitating their own interests and inner sense of agency to learn. Every interaction had to be analysed for learning outcomes (eg what colours are they learning etc?), and the act of logging such details simply took away from real humane adult-child interactions. He was a popular teacher, the children loved him, as the parents constantly told other staff; he was almost unique in being an adult who would get down on the floor at the children’s level and just be with them. They felt heard, understood, safe in his presence and in that atmosphere they developed confidence and grew emotionally and developed cognitively. He has now left the profession, which is a huge loss to the kids.

We might wonder why such emotional understanding as well as touch is so important. As researchers such as Peter Elfer have shown [1], children benefit emotionally and in their learning when their attachment needs are given due attention. However one analysis of over 2000 cases found that, more often than not, in nurseries the predominant attachment styles with staff were of an avoidant or ambivalent rather than a secure kind [2]. Even though some sensitive and well-trained nursery workers can potentially be more sensitive than many parents, even the most sensitive staff member inevitably becomes less sensitive when activity is geared to learning outcomes and institutional needs and those of the group as a whole, rather than to specific children. Childcare providers in day-care settings often feel unable to modulate infant distress, and consequently are less often sought out for comfort. Lamb [3] suggested that children realise that such carers are primarily interested in providing a learning environment and minimising misbehaviour in the interests of group harmony. Richard Bowlby is one voice among many who has argued firmly that attachment needs in nurseries are underestimated, to the detriment of children’s future wellbeing [4].

Yet the lessons the children learn from such encounters are maybe not those intended. They learn to be overly self-reliant, to not trust emotional signals to themselves about their distress, and most importantly, that their emotional needs are too much for most adults. The lack of touch can leave many feeling that their physical needs are too much as well, particularly if innocent comfort seeking or reassurance, such as a 3 year old sitting on a lap, is responded to with rejection and alarm. These children then cannot learn the difference between touch that feels ok and that which doesn’t, and so paradoxically this can make them more at risk.

Some years ago Trudy Marshall , while working for a London local authority, did a study of childcare that brought many of these sometimes upsetting issues to life. She found that many staff were young, little trained and had a fear of getting close to the children or of ‘spoiling’ them. A typical comment made by one staff member was ‘if they cry and it is just because they want to be cuddled, then I would try not to do it’ [5, p. 28] . Dependence was feared and discouraged, and as Marshall wrote ‘there appeared to be an underlying belief that to nurse a child was to spoil him, particularly if he was crying’ [5, p. 24] In these nurseries a child was never held for more than a few seconds, except on arrival, and few received ongoing sustained attention as staff would drift from child to child quickly, concentrating on the group as a whole. Anxious and withdrawn children received even less attention than crying ones, and when children cried, non-mind-minded reasons were generally sought, such as the child being ‘dirty’ or ‘cold’ rather than emotional reasons, such as being sad, homesick, scared, or unhappy. What we saw here is what is becoming endemic in much of professional culture, an emotional distancing, and a reliance on rules and procedures which protect against awareness of the powerful emotional needs of children, such as dependency, vulnerability, fear and a range of anxieties.

Yet we know what a strain going to nursery can be for a little child. Cortisol levels of children starting nursery shoot up compared to those receiving home based care, and it is attachment anxiety that triggers this [6]. Toddlers starting nursery after being at home since birth have cortisol levels between 75 and 100 per cent higher than when they were at home [7]. Secure attachment and good quality  childcare buffers this a bit [8] but even securely attached toddlers show high cortisol reactivity and ‘chronic mild stress’ 5 months after starting nursery. It is shocking that so few nurseries have as yet taken on the lessons of attachment theory.

And what about physical touch, the new taboo? Research is clear that children and infants are soothed by touch [9], which helps to calm emotions, regulating  both heart-rate and blood pressure [10], as studies of adults,  children and young babies attest. Most humans are responsive to touch, and for example waitresses get more tips when they lightly touch a customer’s arm (Guéguen and Jacob 2005). A wife’s fear responses  are quietened  if she holds her husband’s hand  when threatened with an electric shock, and interestingly the better quality the marriage then the less threat related neural activity [12]. We release oxytocin, which normally has a calming effect,  when we have a massage, or are being lovingly touched, and with more oxytocin we generally feel less anxiety or pain, become more generous [13], have lower blood pressure [14], and even pay more attention to the eye-regions of those around us [15].

Being lightly touched helps children feel regulated and enhances delayed gratification [16], one of the best predictors of later life outcomes [17]. Indeed being touched gives rise to many positive changes right down to a cellular level [18].  Well-researched interventions such as ‘kangaroo care’ help reduce mortality and morbidity [19], as can using music therapeutically [20]. In kangaroo care, premature infants are carried upright under their mothers’ clothes. This stabilises heart rate, temperature, and breathing, increases weight gain, decreases crying, and improves sleep, and its effects on emotional regulation and cognitive skills can be seen ten years on [21].

Examples of when babies and young children are emotionally and physically neglected demonstrate the powerful importance of caring touch and emotionally attuned interactions. This was shown tragically in the early studies of Romanian orphans [22], and has been known since the work of Spitz in the 1940’s [23]. More recently studies of Romanian orphans fostered by caring adults have shown huge changes not only in emotional and cognitive development, but also in brain white matter and at an epigenetic level [24].

Of course infants and children who are not given ordinary caring support in infancy, including some physical contact and ordinarily good enough attuned attention, become cut-off from their own emotional needs, and hence perpetuate the current trend in society which is suspicious and even denigratory of vulnerability, neediness and dependency.  This fits well into the ever more powerful neoliberal agenda, which valorises strength, independence and self-sufficiency and can blame the weak, dependent and needy. We know that children whose attachment needs are not met can not only become emotionally distant and cut-off themselves and hence less emotionally literate, empathic or responsive to the needs of others. The risk of this is that we will breed another generation of cut-off adults. Maybe this is hard to take in for political leaders out of touch with their own vulnerability, many of whom were sent early to boarding school [25], [26], but it is nonetheless  tragic and should  be fought against.


[1]        P. Elfer, “Facilitating intimate and thoughtful attention to infants and toddlers in nursery,” in Lived Spaces of Infant-Toddler Education and Care, Springer, 2014, pp. 103–117.

[2]        L. Ahnert, M. Pinquart, and M. E. Lamb, “Security of children’s relationships with nonparental care providers: A meta-analysis,” Child Dev., vol. 77, no. 3, pp. 664–679, 2006.

[3]        M. E. Lamb, “Effects of nonparental child care on child development: an update,” Can. J. Psychiatry, vol. 41, no. 6, pp. 330–342, 1996.

[4]        R. Bowlby, “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,” Attach. Hum. Dev., vol. 9, no. 4, pp. 307–319, 2007.

[5]        T. Marshall, “Infant care: a day nursery under the microscope,” Soc. Work Serv., vol. 32, pp. 15–32, 1982.

[6]        M. G. Groeneveld, H. J. Vermeer, M. H. van IJzendoorn, and M. Linting, “Children’s wellbeing and cortisol levels in home-based and center-based childcare,” Early Child. Res. Q., vol. 25, no. 4, pp. 502–514, 2010.

[7]        L. Ahnert, M. R. Gunnar, M. E. Lamb, and M. Barthel, “Transition to child care: Associations with infant–mother attachment, infant negative emotion, and cortisol elevations,” Child Dev., vol. 75, no. 3, pp. 639–650, 2004.

[8]        L. S. Badanes, J. Dmitrieva, and S. E. Watamura, “Understanding cortisol reactivity across the day at child care: The potential buffering role of secure attachments to caregivers,” Early Child. Res. Q., vol. 27, no. 1, pp. 156–165, st 2012.

[9]        M. T. Fairhurst, L. Löken, and T. Grossmann, “Physiological and behavioral responses reveal 9-month-old infants’ sensitivity to pleasant touch,” Psychol. Sci., vol. 25, no. 5, pp. 1124–1131, 2014.

[10]      G. Esposito, P. Setoh, S. Yoshida, and K. O. Kuroda, “The calming effect of maternal carrying in different mammalian species,” Name Front. Psychol., vol. 6, 2015.

[11]      N. Guéguen and C. Jacob, “The effect of touch on tipping: An evaluation in a French bar,” Int. J. Hosp. Manag., vol. 24, no. 2, pp. 295–299, 2005.

[12]      J. A. Coan, H. S. Schaefer, and R. J. Davidson, “Lending a Hand: Social Regulation of the Neural Response to Threat,” Psychol. Sci., vol. 17, no. 12, pp. 1032–1039, 2006.

[13]      V. B. Morhenn, J. W. Park, E. Piper, and P. J. Zak, “Monetary sacrifice among strangers is mediated by endogenous oxytocin release after physical contact,” Evol. Hum. Behav., vol. 29, no. 6, pp. 375–383, 2008.

[14]      J. Holt-Lunstad, W. A. Birmingham, and K. C. Light, “Influence of a ‘Warm Touch’ Support Enhancement Intervention Among Married Couples on Ambulatory Blood Pressure, Oxytocin, Alpha Amylase, and Cortisol,” Psychosom. Med., vol. 70, no. 9, pp. 976 –985, Nov. 2008.

[15]      A. J. Guastella, S. L. Einfeld, K. M. Gray, N. J. Rinehart, B. J. Tonge, T. J. Lambert, and I. B. Hickie, “Intranasal oxytocin improves emotion recognition for youth with autism spectrum disorders,” Biol. Psychiatry, vol. 67, no. 7, pp. 692–694, 2010.

[16]      J. A. Leonard, T. Berkowitz, and A. Shusterman, “The effect of friendly touch on delay-of-gratification in preschool children,” Q. J. Exp. Psychol., vol. 67, no. 11, pp. 2123–2133, Nov. 2014.

[17]      W. Mischel, Marshmallow Test. New York: Little, Brown and Company, 2014.

[18]      F. A. Champagne, “Epigenetics of mammalian parenting,” Ancestral Landsc. Hum. Evol. Cult. Childrear. Soc. Wellbeing, vol. 18, pp. 18–37, 2014.

[19]      S. L. Green and W. D. Phipps, “Interactional pattern analysis of mother–baby pairs: Kangaroo mother care versus incubator care,” South Afr. J. Psychol., vol. 45, no. 2, pp. 194–206, 2015.

[20]      M. Ettenberger, H. Odell-Miller, C. R. Cárdenas, S. T. Serrano, M. Parker, and S. M. C. Llanos, “Music Therapy With Premature Infants and Their Caregivers in Colombia–A Mixed Methods Pilot Study Including a Randomized Trial,” Voices World Forum Music Ther., vol. 14, no. 2, p. np, 2014.

[21]      R. Feldman, Z. Rosenthal, and A. I. Eidelman, “Maternal-preterm skin-to-skin contact enhances child physiologic organization and cognitive control across the first 10 years of life,” Biol. Psychiatry, vol. 75, no. 1, pp. 56–64, 2014.

[22]      T. G. O’Connor and M. Rutter, “the English and Romanian Adoptees Study Team.(2000). Attachment disorder behavior following early severe deprivation: Extension and longitudinal follow-up,” J. Am. Acad. Child Adolesc. Psychiatry, vol. 39, no. 6, pp. 703–712.

[23]      R. A. Spitz, “Hospitalism—An inquiry into the genesis of psychiatric conditions in early childhood,” Psychoanal. Study Child, vol. 1, pp. 53–74, 1945.

[24]      J. Bick, T. Zhu, C. Stamoulis, N. A. Fox, C. Zeanah, and C. A. Nelson, “Effect of early institutionalization and foster care on long-term white matter development: a randomized clinical trial,” JAMA Pediatr., vol. 169, no. 3, pp. 211–219, 2015.

[25]      N. Duffell, The Making of Them: The British Attitude to Children and the Boarding School System. London: Lone Arrow Press, 2000.

[26]      J. Schaverien, Boarding School Syndrome: The psychological trauma of the “privileged” child. Oxford; Routledge, 2015.



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