Copyright is owned by the Author of the thesis.  Permission is given for 
a copy to be downloaded by an individual for the purpose of research and 
private study only.  The thesis may not be reproduced elsewhere without 
the permission of the Author. 
 



i 

 

 

 

 

 

 

The Foster Caregiving Relationship with Newborns who have Feeding 

Difficulties 

 

A thesis presented in partial fulfilment of the requirements for the  

Master of Arts endorsed in Psychology 

Massey University, Albany, New Zealand 

 

 

 

Nari Hann 

12105657 

2018 

 

 

 

 

 

 



ii 

 

Pepeha 

 

I te taha toku māma    I te taha toku pāpā 

Josephine Barnaby (nee Pryor)  Maxwell Philip Barnaby 

Ko Putauaki te maunga   Tauiwi 

Ko Rangitaiki te awa 

Ko Mataatua te waka 

Ko Nga Maihi te hapū 

Ko Ngāti Awa te iwi 

Ko Nari Elizabeth Hillary Hann toku ingoa 

 

 

 

 

 



iii 

 

Acknowledgements 

Ehara taku toa, he takitahi, he toa takitini 

My success should not be bestowed onto me alone, as it was not individual success but success of a 

collective 

 

Everything good in life stems from a firm foundation and a great upbringing. I am 

fortunate to have had both, so I wanted to start by acknowledging the role my beautiful parents 

have played in providing me with such great opportunities, and instilling into a young girl the 

qualities that have allowed me to persevere and achieve as an adult something that I never 

dreamed I could. My sister Beverley has also been an integral part of that journey, not only as 

my older sibling and role model, but also as my best friend. I thank her for her ongoing 

positivity and encouragement. The relentless support she and her husband James have given 

me throughout this process have never wavered. At times I think she believed more than I did 

that I could actually do it!  

Although completing a thesis was always part of the course programme, I never 

imagined that I would be able to research a topic that I was really passionate about while being 

mentored by such a talented, generous, and encouraging supervisor. Veronica made this 

happen. She supported me throughout this journey and I feel very privileged that I was able to 

learn and be inspired by her. She is truly a great New Zealander, and someone I now call a 

friend. I look forward to many more talks with her about her love for Winston Peters and 

sharing stuff about our families. They are always great conversations. 

There are many people who have contributed in some way to making this project 

happen. To all the caregivers: without your dedication to providing children in care with the 

love and nurturing they require, this project would never have happened. To Bianca and John: 

for being the best second parents anybody could ask for, and for John’s invaluable contribution 



iv 

 

to the final stages of this project. To my great friends and personal support systems, Gill and 

David Parrott, Katie and Brendon Pritchard, Sarah Williams, Linzi Heaney and Jo Stevenson: 

they have all played a fundamental role in supporting me to achieve, and for that I thank them. 

To the Health Research Council of New Zealand: thank you for believing in the importance of 

my research topic, and for providing financial support so I could focus on my studies.  

Of course, I have saved the best for last: Michael, Oscar, Samuel, and Jesse, my 

beautiful, loving, supportive, encouraging, and amazing family. It is so difficult to put into 

words how they have contributed to this achievement. I am so blessed to have a partner in life 

who believes in me and encourages and supports me every day to accomplish my dreams. I 

know this journey has not been easy at times (as I am so often reminded by others who say, 

“Poor old Mike”). All I can say is, “Thank you for hanging in there,” and “Look out, my new 

psychology skills are going to help me win a lot more arguments!” Finally, to my three babies, 

who are my universe: I hope that watching Mummy “do her study” has provided them with 

some positive life lessons, taught them to strive to be the best people they can be, to always 

believe in themselves, and to work hard so all their dreams may come true. I look forward to 

now having every day to focus solely on being their mummy. 



v 

 

Abstract 

The purpose of this study was to expand on foster care and attachment literature by 

investigating how the relationship is impacted between a foster caregiver and newborn who 

experiences feeding difficulties. The most common types of feeding difficulties experienced 

include reflux, allergies, colic, arousal to feed, and sucking problems, with prenatal 

methamphetamine exposure being the most frequently cited reason for causality. Newborns 

who have been prenatally exposed to methamphetamine are at higher risk of preterm births. 

Prematurity has been widely associated with developmental issues in newborns, such as poor 

sucking reflexes. All newborns discussed in this study were of Māori descent, highlighting a 

possible association between Māori children in care and feeding difficulties. This association 

is thought to be strengthened by the social determinants faced by many Māori, and the punitive 

neo-liberal nature of the welfare system. Phenomenological interpretive analysis was used to 

understand the experiences of seven foster caregivers who were highly skilled in caring for 

newborns with feeding difficulties, and how the feeding difficulties could impact the 

attachment relationship and contribute to placement breakdowns. Additionally, the strategies 

that foster caregivers used to minimise the impact of the difficulty and optimise attachment 

interactions were explored. The feeding difficulties of newborns were found to make 

attachment interactions more difficult to achieve, but due to the fortitude of the caregivers in 

providing the best opportunities for newborns in their care, attachment interactions were 

reportedly always accomplished. Although feeding difficulties placed extra demand on the 

caregiver role, the commitment and motivation of the caregivers, and the intervention strategies 

they used to reduce the impact, promoted bonding and stabilised placements. Therefore, 

feeding difficulties were not associated with placement breakdowns. Rather, unanticipated 

extended placement timeframes, which impacted the caregiver’s ability to provide a consistent 

and stable environment, were found to be more detrimental to the placement stability. 



vi 

 

Understanding feeding difficulties and their impact on attachment for babies in foster care is 

crucial when caring for the nation’s most vulnerable citizens and ensuring that they have the 

greatest opportunities for healthy development from the start of their lives. 

 



vii 

 

Table of Contents 

Pepeha ....................................................................................................................................... ii 

Acknowledgements ................................................................................................................ iii 

Abstract ..................................................................................................................................... v 

Table of Contents ................................................................................................................... vii 

Figures and Tables ................................................................................................................... x 

Introduction .............................................................................................................................. 1 

Foster Caregiving ................................................................................................................. 3 

Foster Caregiving in New Zealand .................................................................................... 3 

Maltreatment, Foster Care, and Adverse Outcomes .......................................................... 6 

Foster Caregiver Role, Responsibility, and Credentials .................................................. 10 

Foster Caregiver Training ................................................................................................ 13 

Feeding Difficulties ............................................................................................................ 16 

The Importance of Feeding .............................................................................................. 16 

Feeding Difficulties Defined............................................................................................ 17 

Aetiology of Feeding Difficulties .................................................................................... 19 

Interventions for Feeding Difficulties .............................................................................. 25 

Attachment ......................................................................................................................... 26 

Kinship and Non-Kinship Caregiving and Attachment ................................................... 32 

Māori Culture and Attachment Theory ............................................................................ 38 



viii 

 

Conclusion .......................................................................................................................... 42 

Methodology ........................................................................................................................... 44 

Aims and Rationale ............................................................................................................ 44 

Research Design ................................................................................................................. 44 

Data Collection ................................................................................................................... 45 

Participant Sample Size ................................................................................................... 45 

Semi-Structured Interviews ............................................................................................. 48 

Data Analysis ...................................................................................................................... 49 

Interpretative Phenomenological Analysis ...................................................................... 49 

Ethical considerations ........................................................................................................ 54 

Cultural Considerations ................................................................................................... 55 

Findings ................................................................................................................................... 57 

Theme One: Feeding Difficulties ...................................................................................... 57 

Subordinate Theme Two: Causes of Feeding Difficulties ............................................... 67 

Subordinate Theme Three: The Impact of Feeding Difficulties and the Strategies Used to 

Minimise Them .................................................................................................... 78 

Theme Two: Attachment ................................................................................................... 93 

Conclusion ............................................................................................................................ 110 

He Whakataukī .............................................................................................................. 115 

References ............................................................................................................................. 116 

Appendices ............................................................................................................................ 140 



ix 

 

Appendix A: Information Sheet ..................................................................................... 140 

Appendix B: Interview Schedule .................................................................................... 143 

Appendix C: Participant Consent Form ........................................................................ 144 

Appendix D: Glossary of Māori terms ........................................................................... 145 

 

 



x 

 

Figures and Tables 

Figure 1: The Symptoms of Withdrawal ................................................................................. 24 

Figure 2: Types of Feeding Difficulties and Number of Participants ...................................... 58 

Figure 3: Common Emotions Caregivers Experience when Caregiving ................................. 86 

Figure 4: The Types of Interactions Identified by Participants ............................................... 94 

 

Table 1: Caregiver Characteristics ........................................................................................... 47 

Table 2: Example of Theme Summary Table .......................................................................... 51 

Table 3: Main Themes and their Subordinate Themes ............................................................ 57 

Table 4: Common Feeding Difficulties and their Perceived Causation .................................. 67 

Table 5: The Impact of Feeding Difficulties............................................................................ 78 

 

https://d.docs.live.net/9ee3e8fbd2fffe88/Thesis/Second%20Pass%20(1).docx#_Toc516999896
https://d.docs.live.net/9ee3e8fbd2fffe88/Thesis/Second%20Pass%20(1).docx#_Toc516999897
https://d.docs.live.net/9ee3e8fbd2fffe88/Thesis/Second%20Pass%20(1).docx#_Toc516999899


1 

 

Introduction 

E tama, tangata i akona I te whare, te turanga kit te marae tau ana. 

Children raised well in the home, will stand strong out in the world. 

Children being uplifted from their biological parents is a contemporary issue in New 

Zealand due to the high number of children placed in foster care every year. Oranga Tamariki—

Ministry for Children reports that the number of children and young people in the custody of 

the Chief Executive has increased by seven per cent since June 2016, meaning that actual 

numbers have increased by nearly 400, from 5312 to 5708 children (Ministry of Social 

Development, 2017b). Of these children, 3518 were of Māori descent, representing an 

extraordinary 66 per cent of children in care (Ministry of Social Development, 2017b). These 

statistics highlight not only the prevalence of social and child welfare issues in New Zealand, 

but also the commonality of the over-representation of Māori in the welfare system (Social 

Policy Research Unit, 2016). This over-representation has significant implications for Māori, 

as research shows that many children who enter the child welfare system experience adverse 

outcomes later in life. Therefore, changing the impact the system has on these individuals 

should be prioritised (Brown & Bednar, 2006).  

Current research suggests that the adverse outcomes for children in care are often a 

result of constant placement breakdowns (Brown & Bednar, 2006). Placement breakdowns are 

thought to occur all too frequently for this cohort due to the complexity of their needs (Farmer, 

Moyers, & Lispcombe, 2004). An infant can be uplifted for a multitude of social issues and 

reasons, and the specific needs of each child are very different (Oranga Tamariki, 2017b). 

Often, children in care have experienced trauma, and as a result can experience medical, 

psychological, and behavioural vulnerabilities that can impact the stability of their placements 



2 

 

(Oranga Tamariki, 2017b). One example of these vulnerabilities is infants who experience 

feeding difficulties.  

Feeding time is an important ritual in the infant’s day, when nourishment is given and 

critical attachment opportunities are created (Chatoor, Ganiban, Colin, Plummer, & Harmon, 

1998). Researchers suggest that the development of attachment bonds to significant others is 

an imperative milestone for the developing child (Bowlby, 1958). Adverse outcomes are 

thought to be minimised if attachment to a primary caregiver can occur (Dozier & Rutter, 

2008). However, when feeding times are problematic, it is argued that extra strain is placed on 

the caregiver, which is detrimental to bonding and causes placements to be put at risk 

(Ainsworth, Salter, & Tracy, 1972; Chatoor et al., 1998). To date, research in this area has 

focused on the development of specific attachment patterns between the biological and foster 

caregiver (Dozier & Rutter, 2008; Dozier, Stoval, Albus, & Bates, 2001), and the importance 

of attachment interactions during feeding time has concentrated mainly on breastfeeding vs. 

bottle feeding (Britton, Britton, & Gronwaldt, 2006). There appears to be limited research with 

mixed results on the caregivers’ experience of caring for children with feeding difficulties, and 

the contribution of these difficulties to placement breakdowns.  

Several studies indicate that caregivers often become frustrated during problematic 

feeding times, resulting in diminished motivation to attach and increasing the risk of the 

placement breaking down (Chatoor et al., 1998). However, more recent research has shown 

that attachment can be achieved despite feeding issues, and that factors outside of the 

caregivers’ control contribute to placement breakdowns (Ainsworth et al., 1972; Chatoor et al., 

1998; Morawska, Laws, Moretto, & Daniels, 2014). The attachment relationship between a 

foster caregiver and infant is complex, and understanding how and if unsettled and problematic 

feeding behaviours may impact the caregiver’s willingness and opportunity to attach is 

therefore under-researched, especially in New Zealand. This thesis will explore, through 



3 

 

analysis of interviews with seven foster caregivers, the impact of feeding difficulties on the 

attachment process in foster caregiving relationships in the New Zealand context, and if 

attachment is connected to placement breakdowns. Furthermore, it will explore what 

constitutes a feeding difficulty, the potential etiological causes of feeding difficulties, and 

strategies caregivers use to minimise the impact of problematic feeding times.  

 

Foster Caregiving 

 

Foster Caregiving in New Zealand 

Prior to the inception of the foster care system in New Zealand in the 1880s, children 

without homes were cared for in orphanages and government institutions (Pollock, 2013). In 

the mid-1800s orphanages housed children who had been lost or abandoned by their parents, 

who had been maltreated, were difficult to manage, or were criminals. Orphanages were 

administered by religious orders and held the primary goal of teaching children Christian 

values. In the later part of the 1800s government institutions were also created to house and 

school these children. Institutions were a primary way of coping with this cohort until the 

inception of foster care or extended family care in the 1980s, when it was decided that children 

were better placed within their own extended family unit or with other families (Pollock, 2013). 

Foster care happens when legal custody or guardianship is given to the state in accordance with 

the Care of Children Act 2004. A legal guardian is a person who is responsible for all issues, 

care, rights, and responsibilities of a child. When the biological parent is deemed unfit to parent, 

guardianship is appointed through the New Zealand Family court under the Children, Young 

Persons, and Their Families Act 1989. Regarding the New Zealand foster care system, the new 

guardian appointed would be Oranga Tamariki.   



4 

 

Contemporary foster caregiving in New Zealand is varied, with five different types of 

care provided: emergency, respite, family home, home for life (or permanency), and 

transitional care (Oranga Tamariki: Ministry for Children, 2018c). Emergency care is when a 

child is placed with no notice, and is only for a very short period. Respite care happens when 

the foster caregivers of a child on placement require a short break. Family home care is when 

children are placed in a group home owned by Oranga Tamariki with up to six other foster care 

children. Home for life, or permanent care, is when the Family Court has decided the biological 

parents are unfit and the child or children require a permanent home. This is also referred to as 

home for life. Transitional care happens when a decision about the child’s future is pending, 

and when the Ministry of Vulnerable Children is working with the biological parents and 

family to find a stable and safe environment for the child. These transitional placements are 

only up to six months. In that time Oranga Tamariki will develop a plan for the child. All foster 

caregivers can provide multiple caring services; they are not limited to one type of caregiving 

because the training and screening processes and the skills required are similar for each 

different type. 

As previously mentioned, there are currently 5708 children in foster care, ranging from 

birth to eighteen years old (Ministry of Social Development, 2017b). Statistics show that eleven 

per cent of children in the foster care system are aged between birth and one year, with over 

three quarters of all children in care being Māori (Ministry of Social Development, 2017). The 

overrepresentation of minority cultures in child welfare systems around the world is a common 

circumstance, and not just applicable to Māori in New Zealand. From Australia and the 

Aboriginal and Torres Strait Island children, to America with the Native American and 

African-American children, indigenous children make up a disproportionate number of 

children in foster care (Holzer & Bromfield, 2008). There are differing opinions on why this 

overrepresentation occurs, ranging from reasons of discrimination to the negative impact of 



5 

 

colonisation, resulting in a high proportion of indigenous people experiencing socioeconomic 

hardship (Barth, Wildfire, & Green, 2006; Conn et al., 2013; Franz & Woodward, 2006).  

The overrepresentation of Māori children in state care is a relatively new phenomenon 

due to the change in laws regarding whāngai adoption and urbanisation, which altered the way 

in which Māori could collectively care for their children (Somerville, 2003). Whāngai is a 

traditional Māori adoption system, whereby families gift children to other families for many 

different purposes (McRae & Nikora, 2003). Although in whāngai adoption a child lives with 

another family, they still have close contact with their birth family, and are raised in a collective 

society (Keane, 2011). Whāngai is used for a variety of reasons, such as when bigger families 

are struggling, or when kin are unable to have their own children. Grandparents often whāngai 

their mokopuna (grandchildren) for the purpose of passing on cultural knowledge and values 

(Keane, 2011). For any of these purposes, secrecy of the adoption is not a necessity, as the 

child was safe and treasured. 

The process of whāngai acknowledged the fundamental phenomena that contribute to 

the development of Māori identity and promote holistic wellbeing for Māori children in care. 

The Adoption Act 1955 was in total contrast to the principles of whāngai, as it emphasised the 

need for secrecy with adoption, promoting the importance of complete separation between the 

birth family and the adoptive family (Somerville, 2003). Further legislation such as the Child, 

Young Persons, and their Families Act 1989, the Guardianship Act 1968, and the Family 

Proceedings Act 1980 (Somerville, 2003) also failed to reflect Te Ao Māori, or the Māori 

worldview. The Child, Young Persons, and their Families Act 1989 outlines the rights of 

children and their families, but like the Guardianship Act 1968, it prioritises the paramountcy 

principle above all else. The paramountcy principle is when the safety and welfare of the child 

is fundamental and must always be the primary consideration when making decisions for the 

child (Somerville, 2003). 



6 

 

Wellbeing in Māoridom is closely linked with the individual development of Māori 

identity (Somerville, 2003). Identity is developed through knowledge and connection with 

whakapapa (genealogy). Whakapapa connects Māori to all things living in our world, whereby 

ancestral ties always originate with the gods Ranginui (sky father) and Papatūānuku (earth 

mother) (Taonui, 2011). Whakapapa is the foundation of the affiliation Māori have with 

whenua, which describes where they belong in the world. When children are placed in foster 

care with non-kin caregivers, their opportunity to learn about their identity diminishes 

(Somerville, 2003). Since the recognition of the principles of the Treaty of Waitangi in the 

1970s, there has been some movement in legislation from a nuclear family view of child rearing 

to acknowledging the Māori worldview of a collective approach to parenting. These collective 

values are reflected in the addition of family group conferences in care and protection services, 

and the inclusion in the paramountcy principle of the importance of whakapapa and 

whanaungatanga, by making grandparents co-guardians of the child when in care (Somerville, 

2003). There has been a shift to promote whānau caregivers and primarily place the children 

with whānau first (Murray, Tarren-Sweeney, & France, 2011). Reunification is always 

prioritised, and if a kinship placement is not available, the state tries wherever possible to place 

the child with foster parents of the same culture. Research shows that children who are placed 

in families of the same culture experience greater wellbeing and fewer externalising problems 

(Anderson & Linares, 2012; White, Havalchak, Jackson, O'Brien, & Pecora, 2007). 

Maltreatment, Foster Care, and Adverse Outcomes 

Uplifting a newborn from its birth home is seen by many to be the least preferred option 

of child welfare interventions, because of the potential impact on childhood development 

(Atwool, 2010; Barth et al., 2006; Biehal, Ellison, Baker, & Sinclair, 2011). However, 

consideration of which environment—the home or out-of-home care—is the safest and most 

nurturing for the child is paramount. Invariably out-of-home placements like foster care are 



7 

 

considered to be an effective intervention, and a protective factor, when the child’s safety and 

wellbeing is at risk (Critchley, 2013; Horwitz, Chamberlain, Landsverk, & Mullican, 2010).  

New Zealand has a significant child maltreatment problem compared with other 

countries in the developed world. In the year ending July 2017 there were nearly 15,000 

substantiated cases of child abuse (Breslau et al., 2014; Child Matters, 2017). Given the 

significance of this problem, interventions that can improve the adverse outcomes experienced 

by children who have been maltreated are an essential role of the child welfare system 

(Schinitz, Shulman, & Vig, 2005). Children come to the attention of child welfare agencies for 

a multitude of reasons, all of which involve some form of maltreatment by their biological 

parents, including prenatal abuse (such as exposure to illicit substances in-utero), physical, 

sexual, and emotional abuse, domestic violence, trauma, exploitation, and neglect (Chicchetti 

& Valentino, 2006; Schinitz et al., 2005). The commonality of prenatal substance exposure 

among foster children in New Zealand is unknown, but anecdotal evidence suggests that it is a 

prevalent problem (Miller; 2016; SociaLink, 2017). Evidence from the United States suggests 

that many children in care have been prenatally exposed (U.S. General Accounting Office, 

1995; 1997). The consequence of childhood maltreatment can be extreme and lifelong and is 

associated with disruptions in the neurological, psychological, and social development of 

children (Breslau et al., 2014; Child Matters, 2017; World Health Organisation, 2016; 2017).  

 Maltreated children are thought to suffer up to seven times more acute and chronic 

health conditions compared with non-maltreated children. Many argue that these health 

conditions are a result of the gene by environment interaction, whereby ongoing maltreatment 

causes the child to experience chronic stress, which hinders the development of the brain, 

immune, and nervous systems (Breslau et al., 2014; Fisher, Gunnar, Dozier, Bruce, & Pears, 

2006; Toth, Gravener-Davis, Guild, & Chicchetti, 2013). Consequently, as the child grows, he 

or she is at greater risk of experiencing behavioural problems such as substance abuse, 



8 

 

psychological issues like depression or anxiety, and health problems such as obesity, heart 

disease, cancer, and suicide (World Health Organisation, 2015). To complicate issues, many 

newborns who are removed from their parents have often experienced an abusive postnatal 

environment. This, coupled with an unnurturing prenatal environment, contributes to the child 

experiencing chronic lifelong health disorders (Barth & Brooks, 1998; Barth et al., 2006). 

Common problems experienced by children in care include chronic stress and medical 

conditions, poor mental health, and developmental delays/issues (Schinitz et al., 2005).  

Stress alters the structures in the brain by the abnormal production of cortisol and 

neurotransmitters such as oxytocin and serotonin (Laurent, Gilliam, Bruce, and Fisher, 2014). 

This dysregulation affects the function of the hypothalamic pituitary adrenal (HPA), which is 

thought to be the emotion epicentre of the brain, where stress and emotions are regulated (Luke 

& Banerjee, 2013; Sadock, Sadock, & Ruiz, 2014). Consequently, the altered neurobiology of 

the brain is thought to contribute to psychological problems later in life. Laurent (2014) 

identifies a link between high cortisol levels and internalising behaviours such as anxiety and 

depression, and low cortisol levels and externalising problems such as anger and antisocial 

behaviour. Additionally, emotional dysregulation and disorganised attachment patterns are 

often consequences of maltreatment, when a child is not exposed to positive role modelling, 

boundaries, and socialisation processes from their caregiver, nor offered a secure safe base 

from which to explore the world. Furthermore, children who have been maltreated have often 

missed critical opportunities for bonding to occur (Fonagy, Steele, & Steele, 1991; Shipman et 

al., 2007). 

Research shows that maltreatment has negative consequences on a child’s 

development, but many argue that the foster care environment can also be detrimental to a 

child’s development (Schinitz et al., 2005). Removing a child from their primary caregiver can 

have dire consequences on the child’s ability and opportunity to develop secure attachment 



9 

 

patterns (Altenhofen, Clyman, Baker, & Biringen, 2013; Atwool, 2006). Newborns in foster 

care experience greater developmental, emotional, and behavioural problems compared with 

non-foster care children. As such, the complexity foster caregivers often face in caring for 

children who have health complications is thought to contribute to placement breakdowns, 

resulting in a perpetuating cycle of instability for the child (Barth, 1991). Contrary to this, 

foster care has shown to be the preferred living arrangement for maltreated newborns, as it 

optimises stability and safety compared with their home environment. Providing newborns 

with stability, consistency, and optimising opportunities for positive early life experiences is 

key in reversing the effects of maltreatment and preventing further adversity throughout their 

lives (Centre for Social Research and Evaluation, 2012).  

The negative developmental consequences of uplifting a child into the foster care 

system can be minimised if the child is provided with a stable, nurturing environment (Atwool, 

2006; Chicchetti, Rogosch, & Toth, 2006). Reduction of placement breakdowns and 

minimising the number of placements a child experiences while in care are thought to be vital 

(Centre for Social Research and Evaluation, 2012), as is the role of the foster caregiver in 

providing a nurturing environment whereby quality attachment interactions are prioritised 

(Bernier & Dozier, 2003). Providing a nurturing environment where bonding is achieved is 

sometimes thought to be overlooked in the foster care system (Stukes-Chipungu & Bent-

Goodley, 2004). The challenges child welfare systems are faced with are thought to be 

extensive, and therefore the fundamental goal of foster care becomes primarily about safety 

(Barbell & Freundlich, 2001). Training and support is often centred around the paramountcy 

principle and physical wellbeing, while disregarding phenomena thought to promote emotional 

wellbeing such as bonding and nurturing. Factors which further confound this issue involve the 

short-term, temporary nature of placements and the health complexities many children in care 

experience (Jacobsen, Ivarsson, Wentzel-Larsen, Smith, & Moe, 2014). Foster caregivers are 



10 

 

often so consumed with dealing with special medical needs that important developmental 

interactions, such as bonding, are often neglected. (Fisher et al., 2006).  

 Ensuring the foster care system prioritises the factors that promote an emotionally 

nurturing environment within a primary caregiver-child relationship is critical for healthy 

development (Hillen & Gafson, 2015). The National Centre for Injury and Prevention (CDC) 

(Child Matters, n.d.) has developed a framework that identifies the essential factors children 

need in out-of-home care in order to achieve positive development and reach their milestones. 

The framework is closely aligned with the fundamental concepts of Bowlby’s attachment 

theory, and advocates the importance of a stable, caring, and safe environment for children to 

grow, learn, and develop. When a child is taken out of a stressful environment and placed into 

a foster care environment, the role of the caregiver and the environment the caregiver provides 

the child both play a significant role in promoting positive childhood development and 

minimising the child’s vulnerability to adversity. 

Foster Caregiver Role, Responsibility, and Credentials 

Given the vulnerability and complex needs of children in care, and the medical fragility 

of some children, the character and credentials of the foster caregiver are fundamental. When 

becoming a foster caregiver, individuals go through a screening process to ensure their 

suitability (Child Matters, n.d.). The screening process is used to ensure that the applicant can 

keep the child safe and has the right character to provide quality care to the child (Child Matters, 

n.d.; Oranga Tamariki, 2018a). Many argue that foster caregivers need to be well adjusted, 

have worked through any of their own family problems, and are able to provide an empathetic 

and nurturing home for the child (Dozier et al., 2001). Therefore, the historical background of 

the caregiver, their upbringing, and their family life are all relevant. Likewise, the caregiver’s 

parenting style, emotional availability, mental health, and personality traits (Dozier et al., 2001; 

Lang et al., 2016) are also relevant. Although little is known about the relationship between 



11 

 

caregiver temperament and child adjustment, Dubois-Comtois et al. (2015) contend that the 

persona of the caregiver is closely linked to how successful a child in care adjusts to different 

situations. The screening process is carried out through a series of interviews in different 

settings, such as the caregiver’s home. Screening is also undertaken through police vetting 

services and by checking that official documentation is authentic (Oranga Tamariki, 2018a). 

Understanding the motivations behind why a caregiver becomes a caregiver is 

considered by some to be an integral part of the recruitment process (Bates & Dozier, 2002; 

Bernier & Dozier, 2003; Beuehler, Cox, & Cuddeback, 2003). While there is limited research 

on how a caregiver’s motivation impacts the attachment relationship, Cole (2005) suggests an 

association between motivational factors and the quality of attachment interactions a caregiver 

can provide. Given the significant link between attachment and childhood development, foster 

care motivation is fundamental to optimising opportunities for attachment (Brown, Bakeman, 

Coles, Platzman, & Lynch, 2004). Caregivers have conscious and unconscious motives for 

caregiving. Those who are motivated to fulfil their own needs increase the likelihood of 

placement breakdowns, whereas caregivers who are motivated for the good of the community 

minimise the likelihood for placement breakdowns (Cole, 2005; Miller, 1993).  

There are two prominent theoretical perspectives that help understand a caregiver’s 

motivation: the altruistic model, and the exchange model (Kang, 2007). The altruistic model 

aligns with the Miller (1993) and Cole (2005) argument about caregiver motivation, whereby 

the caregiver is motivated by doing something positive for the people around them by helping 

and promoting wellbeing for others. Individuals who have altruistic motives are thought to 

make decisions based upon what is good for their community and those in need. Altruistic 

caregivers have a great deal of empathy, which provides them with a good foundation when 

caring for vulnerable children, and the altruistically motivated caregiver promotes placement 



12 

 

stability because of his or her commitment to providing the child with the best opportunities 

(Kang, 2007). 

In contrast, the exchange model argues that caregiving is based on a reward/cost view 

of relationships. Social exchange theory provides an explanation of this model of caregiving 

(Homans, 1961; Kang, 2007; Stukes-Chipungu & Bent-Goodley, 2004). In this approach, a 

caregiver’s motivation is formed from an individual’s evaluation of the rewards versus the cost 

(Timmer et al., 2004). When the rewards outweigh the costs, individuals are thought to 

experience greater motivation to pursue a relationship. Rewards may come in different forms, 

such as approval from others, monetary gains, and greater social popularity. Costs involve such 

things as being condemned by others, monetary losses, and social rejection (Timmer et al., 

2004). Social exchange theory is often applied to interpersonal relationships such as the dyad 

between a foster caregiver and newborn (Stukes-Chipungu & Bent-Goodley, 2004). Timmer 

et al. (2004) found that a caregiver’s motivation changed when the needs of the newborn 

became more complex. Employing a rational decision-making process, caregivers are thought 

to consider the emotional and financial impact of providing care for this cohort, as well as how 

it will impact their personal responsibilities and their household. Kinship caregivers experience 

a different rational process because of the familial investment they naturally have when caring 

for a related newborn (Timmer et al., 2004). Kin caregivers are more likely to promote 

placement stability and optimise attachment interactions compared with non-kinship caregivers 

(Comp, 2018). However, Berrick (1997) disagrees, suggesting that non-kinship caregivers can 

be as emotionally motivated as kin-carers. 

It is likely that there is an interplay of both altruism and social exchange theories in 

explaining foster carer motivation. Committing to foster caregiving is arguably more than 

making a rational choice between costs and benefits and incorporates a wide range of other 

considerations (Klein & White, 1996; Cole, 2005; Timmer et al., 2004). Welcoming a newborn 



13 

 

with complex needs into your home, providing high quality care, meeting the newborn’s needs, 

and incorporating their complex needs into your day-to-day life is a significant commitment. 

The commitment required is two-fold; emotional and physical. The emotional commitment 

involves nurturing, empathy, understanding, and patience whilst also being mindful of creating 

space for quality attachment interactions to occur (Dozier & Rutter, 2008). The physical 

commitment is more practical in nature, whereby the caregiver needs to create flexibility within 

the home environment and a strong personal support network to meet the child’s special needs. 

Likewise, consideration regarding the biological children or other members in the household 

is also important (Dozier & Rutter, 2008). Children who are medically fragile and vulnerable 

require a different level of care to other children, thus impacting households and the everyday 

life of the caregiver.  

Foster Caregiver Training 

To care for these often medically fragile and vulnerable children, initial and ongoing 

foster caregiver training is vitally important. Foster caregiving is an extremely challenging and 

demanding role, which requires caregivers to have specialised knowledge (Stukes Chipungu & 

Bent-Goodley, 2004). Caregiver training is often limited to induction training, which is 

compulsory for everyone as part of the recruitment process. However, Horwitz et al. (2010) 

argue that foster care training should be ongoing, encompassing much more than how to be a 

caregiver and how to provide a safe home for children. Horwitz suggests that training that 

acknowledges the importance of the emotional and psychological needs of the child should be 

standard practice. Children placed in foster care have the legal right to not only be provided 

with a safe home, but also to have opportunities for positive growth and development. 

However, research indicates that there is negligible training offered around complex needs and 

trauma, which so many children in care experience (Kinsey & Schlosser, 2012). It is reported 

that just under a third of caregivers feel confident in what they know and what they have learnt. 



14 

 

However, most caregivers report that they have received insufficient training from their agency 

and have often felt undervalued and underequipped to provide the right care for the child. 

Puddy and Jackson (2003) found that most introductory caregiver training packages were 

devoid of modules that encompassed the wide range of skills essential to caregiving.  

Providing caregivers with specialised training on how to manage and care for children 

with complex needs is extremely important, as many children who enter foster care experience 

health complications that require special needs. Newborns, for example, are often prenatally 

exposed to drugs, and are experiencing withdrawal and other health complications such as 

difficulty with feeding and respiratory problems (Lenora, 2010; Marcellus, 2004). These babies 

experience a range of difficulties due to the non-homogenous impact of different drugs, 

alcohol, and tobacco, making their needs complex and divergent (Lenora, 2010). Providing 

caregivers with the skills to manage their unique requirements is a difficult task for foster care 

agencies. Caregivers require training and a good professional support network to help them 

effectively manage the child’s care requirements (Barth, 1991) and reduce complex childhood 

behaviours (Barth, 1991; Fukkink & Lont, 2007). Regular respite with a consistent respite 

caregiver was also identified as a significant factor in promoting caregiver wellbeing and 

stability of placements (Fukkink & Lont, 2007). 

The training offered to caregivers in New Zealand is varied and depends on the 

organisation. Oranga Tamariki (2018b) provides a non-compulsory national caregiver training 

programme that delivers workshops about different aspects of caregiving. Modules include: 

attachment and resilience, child development, understanding and managing behaviour, carer 

families, health and wellbeing, identity and belonging, legal issues, maltreatment and family 

violence, safety prevention, teamwork, and working with adolescents. While these workshops 

are optional for caregivers, Oranga Tamariki (2018b) recommends that caregivers should 

consider the attachment and resilience, child development, and understanding and managing 



15 

 

behaviour workshops as a priority. Besides the optional workshop of identity and belonging, 

only limited cultural training is compulsory and offered within Oranga Tamariki’s induction 

package. There appears to be no mention of ongoing and specific cultural training regarding 

Māori cultural norms and protocols. Given the over-representation of Māori children in the 

foster care system and the adverse outcomes they are faced with throughout their lives, 

incorporating and prioritising cultural awareness and sensitivity in foster caregiver training 

should be mandatory (Brown, Sintzel, Arnault, & George, 2009).  

Brown et al. (2009) showed that caregivers are willing and motivated to learn more 

about a child’s culture and suggest that cultural training should occur on different levels, not 

only through education, but also through ongoing cultural supervision, support, and connection 

to the community. Culture plays a fundamental role in childhood development, particularly for 

the indigenous, for whom wellbeing is defined through a holistic lens (Brown et al., 2009). The 

collective nature of indigenous communities suggests that connection to the wider community 

and to their extended birth families is key to promoting holistic wellbeing (Chipungu & 

Goodley, 2004)). Identity is paramount in Māori culture, and although children in care are not 

residing with their biological family, they will always be Māori, and therefore should always 

be provided with opportunities to stay connected to ensure their holistic wellbeing, which is 

their fundamental right (Haenga-Collins & Gibbs, 2015; Marsden & Royal, 2003). Promoting 

cultural competence, awareness, and sensitivity should occur at an organisational level and be 

reflected in policies, assessments, and interventions, and at a frontline service delivery level, 

whereby caregivers are provided with the skills to properly understand how to develop a 

cultural connection for the child.   

  



16 

 

Feeding Difficulties 

 

The Importance of Feeding 

Feeding is the human process of acquiring food orally through the mouth and is a critical 

element of human neurological and psychosocial development (Hardy, Senese, & Fucile, 2018; 

Sanders-Phillips, 1998). Obtaining food is thought to be culture-specific, in that different 

cultural practices influence the way in which an individual interacts with his or her environment 

to obtain food (Rudolph, 1994). Throughout life, feeding provides individuals with nutrients 

that are critical for growth, development, and functioning. Many argue that feeding for a 

newborn is so much more, as it provides the mother-child dyad with opportunities to interact 

(Ainsworth et al., 1972).  

Feeding and sucking skills are thought to evolve prenatally and usually develop rapidly 

in the first few days after birth (LaGasse et al., 2003). It is argued that disruptions in any part 

of the feeding process affect the entire human system, with many suggesting that newborns 

who are unable to learn to feed normally may experience adversity and struggle with feeding 

throughout their lifetime (Meadows, 2015; Williams, 2003; Yang, 2017). The feeding process 

is a biologically, neurologically, and psychosocially based process (Rudolph, 1994; Hardy et 

al., 2018). The neurologically and biologically based processes involve normal human brain 

development and growth (Ross & Browne, 2013). The psychosocial process involves the 

development of behavioural skills, social interaction, and emotional regulation (Hardy et al., 

2018). Rudolph (1994) describes a systemic process that begins in-utero, where the foetus 

develops the sucking mechanism. Swallowing is the next part of the process, and is made 

possible through both psychological and neurological processes through which the individual 

requires purposive motivation and the digestive capability to cease breathing and swallow 

(Ross & Browne, 2013). From here the digestive system takes over and processes the food 



17 

 

through the oesophagus and stomach, resulting in digestion and nutrient absorption. (Rommel 

et al., 2003; Rudolph, 1994; Sanders-Phillips, 1998).  

After birth, biological and neurological development still occurs and the psychosocial 

processes begin (Rommel, De Meyer, Feenstra, & Veereman-Wauters, 2003). For example, 

Sigmund Freud’s oral phase of psychosocial development supports the concept of development 

occurring psychosocially as well as biologically and neurologically during feeding. The 

caregiver role is imperative in developing attachment and promoting psychological wellbeing 

for the newborn, which is thought to occur primarily during feeding time. Through interactions 

with a maternal figure during feeding, newborns develop an understanding of being in the 

world. They learn to explore within a secure base and receive feedback regarding appropriate 

and inappropriate behaviours (Bretherton & Munholland, 2008; Mooney, 2010). When issues 

occur during feeding, oral fixations may develop, which could impact the individual’s view 

and experience of the world and behaviour throughout their lifespan (Mooney, 2010). These 

fixations parallel concepts discussed widely in the literature regarding the importance of 

attachment theory and the consequences of poor attachment interactions during infancy 

(Kronstadt, 1991; Rommel et al., 2003; Rudolph, 1994; Smith & Ellwood, 2011; Twomey et 

al., 2013).  

Feeding Difficulties Defined 

Feeding difficulties affect 25 per cent of all children and 80 per cent of developmentally 

delayed children (Manikam & Perman, 2000; Williams, 2003; Yang, 2017). The number of 

children in foster care with feeding difficulties is unknown in New Zealand and around the 

world. However, anecdotal information provided to foster caregivers suggests that feeding 

difficulties are a common problem faced by many children in care (Children’s Hospital 

Philadelphia, 2018; Satter, 2018; Perpetual Fostering, 2018). Most feeding difficulties occur 

under the age of two, and the greatest difficulties are for children during the first year of life. 



18 

 

However, some feeding difficulties are lifelong and continue throughout an individual’s 

lifespan (Meadows, 2015).  

Differentiating between a feeding difficulty and a feeding disorder is considered critical 

to assessment and intervention (Yang, 2017). A feeding difficulty encapsulates all types of 

feeding issues that impact the process of an individual obtaining food. In contrast, a feeding or 

eating disorder is an enduring disturbance in eating behaviour that can be diagnosed through a 

set of consistent criteria (Yang, 2017). It is suggested that due to the impact on a child’s neuro 

and psychosocial development, identification, multidisciplinary assessment, and ongoing 

intervention are critical to minimising the effects (Hardy et al., 2018; Meadows, 2015; Rommel 

et al., 2003). The impact of feeding difficulties can significantly change the feeding experience 

for both the caregiver and the newborn. The anxiety that both a caregiver and newborn may 

experience during feeding can cause further feeding maladaptation and secondary problems, 

perpetuating anxiety further. Therefore, early identification of feeding difficulties is described 

as a critical step in minimising the impact of the feeding difficulty on both the newborn and 

the caregiver (Hardy et al., 2018).  

Williams (2003) identifies six different types of feeding difficulties: pickiness, refusal, 

overeating or undereating, slowness, painfulness, choking, gagging, and vomiting. In addition 

to Williams’ identification, Yang (2017) recognises newborn aspiratory and respiratory issues, 

gastroesophageal issues, and allergies as types of feeding difficulties. Many authors refer to 

reflux as having the greatest prevalence. Reflux is not only described as a primary feeding 

difficulty, but also a secondary difficulty due to the biological nature of its aetiology and the 

further feeding complications created by it, such as refusal to feed, vomiting, and screaming 

(Meadows, 2015; Rudolph, 1994). Reflux is a gastroesophageal problem caused by a sphincter 

that does not close properly after ingestion (Meadows, 2015). Reflux occurs more frequently 

in babies under six months of age and manifests by causing pain and discomfort during the 



19 

 

feeding process, which often results in vomiting. The issues caused by reflux provide a good 

example of how one difficulty can lead to other difficulties through the development of 

maladjusted feeding behaviours which evolve to minimise the pain and discomfort caused 

(Meadows, 2015). 

Allergies are also a common feeding difficulty, particularly for Māori compared with 

non-Māori babies, whereby 38 per cent of Māori newborns experience allergies (Crooks et al., 

2010; Ministry of Health, 2009). Allergies are thought to be a prevalent issue for children in 

care, given the need for formula feeding and the significant connection between cow’s milk 

and allergies in newborns (Luccioli, Verrill, Ramos-Valle, & Kwegyir, 2014).  

Aetiology of Feeding Difficulties 

Aetiology of feeding difficulties is often discussed in terms of organic or non-organic 

causes (Burklow, Phelps, Schultz, McConnell, & Rudolph, 1998; Rommel et al., 2003; 

Williams, 2003; Yang, 2017). Organic feeding difficulties are issues with structure 

abnormalities in the digestive process, such as tongue tie or cleft palate, and neurological 

disorders such as cerebral palsy (Yang, 2017). Non-organic feeding difficulties, on the other 

hand, are more behavioural, and develop through environmental and social origins (Burklow 

et al., 1998). There is ongoing debate regarding organic versus non-organic aetiology, with 

some researchers arguing that feeding difficulties always have organic causes, others 

contending only organic causes, and some suggesting that feeding difficulties occur on a 

continuum of both organic and non-organic causes (Manikam & Perman, 2000; Williams, 

2003; Yang, 2017). Due to the complex manifestation of feeding difficulties, a comprehensive 

assessment to identify the individualised organic and non-organic factors contributing to the 

problem is best practice (Burklow et al, 1998). 

Research shows that determining the cause of a feeding difficulty involves 

consideration of multiple social, neurological, biological, and behavioural factors (Burklow et 



20 

 

al., 1998; Mahony & Murphy, 1999). Sanders-Phillips (1998) argues that understanding the 

aetiology of a feeding difficulty is a critical element of successful management. To understand 

the factors that need consideration during assessment, specific variables have been identified 

which are thought to be significantly related (Meadows, 2015; Rommel et al., 2003; Sanders-

Phillips, 1998). Social influences such as poverty and maternal health and wellbeing during 

and after pregnancy are thought to be fundamental (Sanders-Phillips, 1998). The negative 

effects of poverty show that impoverished individuals are often less educated, have poorer 

health and wellbeing behaviours, are more likely to experience mental illness, and are at greater 

risk of engaging in criminal activities and antisocial behaviours (Luccioli et al., 2014; Rommel 

et al., 2003). Maternal adoption of unhealthy habits and substance abuse during pregnancy are 

two significant issues for at-risk individuals, and are prevalent aetiological factors among 

newborns with feeding difficulties in foster care (Jadcherla et al., 2017; Mahony & Murphy, 

1999).  

Nutritional intake and prenatal and antenatal care are important factors for any 

expectant mother to prioritise during pregnancy. The lack of an appropriate diet and regular 

check-ups to ensure the unborn baby is thriving in utero increases the likelihood of foetal 

abnormalities (Jadcherla et al., 2017; Maya-Enero et al., 2018). Poor maternal nutrition restricts 

the amount of nutrients and oxygen going to the unborn baby, increasing the risk of negative 

effects on the baby’s growth and structural neurological development (May-Enero et al., 2018). 

Substance abuse during pregnancy is another maternal health problem that is frequently linked 

to causation for newborns with feeding difficulties in foster care (Mahony & Murphy, 1999). 

Breastfeeding is also critical for a child’s healthy development, with bottle feeding considered 

by some to be a cause of feeding difficulties due to the allergies that babies can develop on 

cow’s formula. Breastfeeding is also thought to be a basic human right of the baby and should 

be encouraged wherever possible (Gribble & Gallagher, 2014). Given the secretive and 



21 

 

personal nature of these maternal lifestyle choices, differentiating between which factor is more 

significant in influencing the outcomes for the newborn is generally problematic (Kronstadt, 

1991; Mahony & Murphy, 1999). 

Prenatal exposure to substances is thought to be a significant aetiological factor for 

many vulnerable newborns in foster care (Eiden, 2001; LaGasse et al., 2003; Smith & Santos, 

2016). Research is limited in this area, particularly in New Zealand, which many authors argue 

is due to the lack of disclosure and impossibility of disentangling the what, when, how much, 

and for how long of issues related to drug and alcohol use (Jaques et al., 2014; LaGasse et al., 

2003). The chaotic lifestyles of drug users place drug-dependent mothers at greater risk of 

parenting problems as well as financial, social, and psychological problems, all of which 

contribute to the critical factors underlying abuse, neglect, and abandonment of children 

(Regan, Ehrlich, & Finnegan, 1987).  

The polydrug issue only consolidates the problematic nature of determining what effect 

the substances have had (Kronstadt, 1991). Given these complexities, a small body of research 

has identified several common themes to maternal substance use and outcomes for newborns. 

Studies show that many polydrug users abuse alcohol and cannabis and smoke cigarettes 

(Shannon, Blythe, & Peters, 2016; Smith & Santos, 2016). There is extensive evidence 

describing the impact of alcohol on the unborn foetus, but less is known about the impact of 

cannabis and nicotine. Some foetal alcohol spectrum disorders (FASD) in newborns are similar 

to the effects of feeding difficulties, such as short height, low body weight, and small head size 

(Kronstadt, 1991). Similarly, nicotine is associated with low birth weight and decreased length 

and head circumference in newborns, and current research suggests no apparent relationship 

between cannabis and feeding difficulties (Barros, Guinsburg, Mitsuhiro, Laranjeira, & 

Chalem, 2011; Edens, 2016).  



22 

 

Alcohol, nicotine, and cannabis are the substances most widely abused by expectant 

mothers, but methamphetamine (meth) is fast becoming a drug of choice, especially in New 

Zealand (Edens, 2016). Meth is an illicit drug that stimulates the central nervous system, and 

is the strongest and purest form of amphetamine type stimulants (ATS) (Community Alcohol 

and Drug Services, 2017). The short-term physical effects of meth use can escalate blood 

pressure, pulse, breathing, and body temperature, causing increased alertness, wakefulness, 

restlessness and energy. The long-term effects of meth use can include addiction, chronic 

fatigue, mental illness, heart failure, stroke, changes to brain structure and function, deficits in 

thinking and movement, and dental problems (NZ Drug Foundation, 2017).  

The effects of meth use on an unborn baby are considered to negatively impact a baby’s 

healthy development. Prematurity, low birth weight, small head circumference, and delayed 

motor development are identified as three of the most common consequences associated with 

prenatal exposure to meth (Kronstadt, 1991; LaGasse et al., 2003; Ross & Browne, 2013; 

Wallace & Belcher, 1997). Furthermore, chronic medical conditions linked to meth use during 

pregnancy include cardiac and respiratory issues, seizures, developmental issues caused by 

premature births, and birth defects. (Schinitz et al., 2005; Schmidt et al., 2018; Smith & Santos, 

2016). Emerging information regarding the impact of meth on newborns suggests that babies 

who have been exposed to meth usually experience sleeping and feeding problems (Schmidt et 

al., 2018). Meth-related feeding difficulties cause disorganised-type feeding patterns, wherein 

newborns can be difficult to rouse to feed and difficult to settle once fed. Feeding time is 

thought to be interrupted for prenatally exposed infants due to the complications of their 

conditions on the actual ritual of feeding, and on the patience and responsiveness of the 

caregiver (Kronstadt, 1991).  



23 

 

The commonality of preterm births in newborns exposed to meth is closely linked to 

the aetiology of feeding difficulties. Although research is limited in this area, existing studies 

suggest that premature newborns are at greater risk of experiencing feeding difficulties due to 

the preterm impact on the development of such things as their cognitive and digestive system 

function, and their sucking ability (Jadcherla et al., 2017). Prematurity is associated with 

neurodevelopmental issues, and premature newborns are at greater risk of encountering 

sucking and swallowing issues due to the disruption to neurological and biological 

development and the impact of tube feeding (Jadcherla et al., 2017; Williams, 2003). Tube 

feeding is often an intervention used on preterm babies when they are too young to feed for 

themselves. Although tube feeding for some newborns is the only way to ensure they are 

receiving nutrients, research suggests that it can have some detrimental consequences on the 

development of feeding skills such as sucking (Williams, 2003; Yang, 2017).  

Some babies who have been prenatally exposed to drugs may experience neonatal 

abstinence syndrome (NAS). NAS is the withdrawal process that affects the central nervous 

system, and although the drug source has been removed, their dependence remains (Smith & 

Santos, 2016). Symptoms are experienced differently by every newborn, and depending on the 

severity of symptoms and medical complications caused by the drug, the baby may be kept in 

the hospital for monitoring (American Academy of Pediatrics, 2002). Symptoms of withdrawal 

are shown in Figure 1. It is purported that babies who experience withdrawal are unsettled and 

require a high level of postnatal care (American Academy of Pediatrics, 2002). The complexity 

involved in caring for newborns while they are withdrawing can be extremely difficult on even 

the most responsive caregiver, impacting the opportunity for important caregiver-newborn 

bonding time and increasing the pressure and demand on the maternal role (Kronstadt, 1991). 

The symptoms of withdrawal can also perpetuate further health complications due to the 

potential risk of malnutrition, resulting in failure to thrive and stress for the newborn (Smith & 



24 

 

Santos, 2016). The stress that is experienced by the newborn at such a young age has shown to 

be associated with altered neurodevelopment, increasing the likelihood of adverse outcomes 

later in life (LaGasse et al., 2003; Sanders-Phillips, 1998; Smith & Santos, 2016; Twomey et 

al., 2013).  

 

Due to the complex aetiology of many feeding difficulties, there is no standardised 

understanding of how each type of difficulty will manifest. Every child experiences feeding 

difficulties in different ways. Therefore, a thorough assessment and individualised intervention 

plan is imperative to minimise the impact of the difficulty on the newborn and the caregiver, 

as well as to ensure the newborn is thriving (Meadows, 2015; Yang, 2017). The importance of 

a multidisciplinary approach to assessment and intervention is vital, with speech therapists, 

SYMPTOMS OF 
WITHDRAWAL

poor 
feeding and 

sucking
dehydration

high-pitched 
consistent 

crying

yawning and 
sneezing

vomiting 
and 

diarrhoea

sleep 
problems

tight muscle 
tone

hyperactive 
reflexes

seizures

drowsy

floppy

fever

sweating

 

Source: Kronstadt, D. (1991). Complex development issues of prenatal drug exposure. The Future of Children, 1(1), 26-49. 

Figure 1: The Symptoms of Withdrawal 



25 

 

occupational therapists, medical staff such as doctors and nurses, dieticians, and behavioural 

psychologists all critical for the best outcomes (Rommel et al., 2003; Rudolph, 1994; Yang, 

2017). Undertaking an assessment process that involves obtaining the detailed historical and 

background information of the newborn and the parent, including their medical, feeding, and 

dietary history, is the first necessary step. Furthermore, a physical examination and observation 

during feeding time will help identify what is going on for the newborn during feeding (Bache, 

Pizon, Jacobs, Vaillant, & Lecomte, 2014; Meadows, 2015; Rudolph, 1994; Williams, 2003). 

A thorough assessment is thought to promote best management by identifying the primary and 

secondary problems occurring, and informing the types of interventions required.  

Interventions for Feeding Difficulties 

Interventions may take on many different forms. Depending on the cause and the type 

of feeding difficulty, caregivers may use a multitude of strategies to help minimise the impact 

during feeding time. Some babies require behaviour modification, as they have developed 

maladjusted feeding behaviours in response to negative past feeding episodes (Meadows, 

2015). Other strategies include altering the way the baby is fed, such as the position in which 

they are held, and the surroundings, including the noise, brightness, and temperature (Williams, 

2003). Using different products, such as different teats and bottles, or sleeping aides to slightly 

raise the baby’s head or keep them on their side is beneficial for some newborns.  

At times newborns will require medical intervention of some description, for example 

tube feeding or special medication. Oral stimulation of some form when a newborn is tube-fed 

will minimise the impact by promoting the sucking reflex to develop (Bache et al., 2014). A 

fundamental strategy for successful feeding begins with the caregiver’s responsiveness and 

wellbeing (Williams, 2003). Remaining calm and relaxed during feeding is also a critical 

strategy to calm the baby and promote attachment interactions (Yang 2017). When caring for 

newborns who have been prenatally exposed to meth, strategies often relate to creating a 



26 

 

soothing, relaxing, and quiet atmosphere, dimming the lights, and reducing the stimulation in 

the room (Smith & Santos, 2016).  

Attachment 

Grand theories of human development try to explain various aspects of development 

from birth to adulthood, including social, emotional, and cognitive growth (Cherry, 2017). Mini 

theories, on the other hand, are used to explain a specific aspect of development, such as self-

esteem, and are often preferred in the face of modern research because of their specificity 

(Cheery, 2017). Grand theories contain comprehensive ideas about development, use a stage-

like progression, and are often used as the basis for further exploration and mini-theory 

development. Grand theories are generally proposed by big thinkers, like Freud and 

psychoanalysis, Skinner and behaviourism, Piaget and cognitive theory, and Erikson and 

psychosocial development (Cherry, 2017).  

Early ideas of attachment during human development emerged in the 1900s from 

Freud’s psychosexual theory (Sadock et al., 2014). According to Freud, children develop in 

five stages, each stage focusing on a different body part, which provides the child with an 

opportunity to seek pleasure (Sadock et al., 2014). In the early stages of development, the 

pleasure-seeking behaviours are reliant on the mother or primary caregiver, considered central 

to the child’s healthy development. Freudian ideas were developed further within object 

relations theory, wherein early relationships with significant caregivers are thought to be the 

foundation of an internal working model, which is the fundamental way in which individuals 

perceive relationships throughout their lifetime (Sadock et al., 2014). 

Object relations theory (Mary, 1969) purports that the experiences that infants have of 

others and their environment during these early stages determines the way in which a child’s 

psyche develops and the way in which they perceive the world. When the infant’s needs are 

being met, the child moves on to the next psychosexual stage, and has a well-adjusted object 



27 

 

relational image of the mothering role. When the mother is neglectful, the child can become 

fixated at this stage and form an abnormal object relational image. The performance and 

behaviour of the primary caregiver becomes an unconscious image in the child’s mind. This 

image is held throughout their lifespan and determines how they predict, understand, and 

behave in social situations and interactions (Mary, 1969). This psychoanalytic interpretation of 

a child’s development has been widely critiqued over the years, but it is important to note 

because of its foundational contribution to Bowlby’s theory of attachment. 

Attachment theory (Bowlby, 1958a) is a widely used and extensively researched theory 

regarding the mother-child relationship and the link between this relationship, childhood 

development, and any adverse outcomes experienced throughout the lifespan. Within this 

theory, attachment is seen as a phenomenon experienced between an infant and primary 

caregiver that is said to provide the infant with the tools to navigate relationships and regulate 

behaviours (Prior, Glaser, & Focus, 2006; Rees, 2007). Bowlby (1982), known for his 

comprehensive work around the mother-infant relationship, defined attachment as an innate 

and universal emotional connection, where an enduring bond connects one person to another. 

Attachment is said to develop gradually over time with an early objective of maintaining 

proximity to the primary caregiver, who provides safety and security. The feeling of security 

allows the infant to explore the world from a safe and secure base. Within this interaction, the 

child also learns how to behave and regulate their emotions in various social situations 

(Ainsworth, 1973; Sadock et al., 2014). The process is facilitated by both the primary caregiver 

and infant and is strengthened by the quality of attachment interactions rather than the amount 

of time spent together (Klaus & Kennell, 1976). Children who have not attached to a primary 

caregiver are thought to be at greater risk of social, emotional, and cognitive maladjustment 

(Bowlby, 1982; Hillen & Gafson, 2015). Subsequently, attachment theory has become a widely 

researched and extensively used theory for childhood development.  



28 

 

Bowlby argued that attachment is biologically driven and is inherent and innate in 

everyone (Sadock et al., 2014). In contrast, behavioural theories propose that attachment is 

learnt through both classical and operant conditioning, and the provision of food (Dollard & 

Miller, 1950; Klaus & Kennell, 1976). Bowlby disagreed, suggesting the mother-infant 

relationship is based upon more than just feeding as a reward.  

Bowlby was influenced not only by psychoanalysis and object relations theory, but also 

by Harlow’s (1958) work with monkeys, and Ainsworth’s seminal work on attachment in the 

strange situation (Mooney, 2010). Harlow’s (1958) studies were significant to Bowlby’s 

theories by showing the emotional and behavioural effects on monkeys who had been isolated 

from their mothers. The isolated monkeys were more withdrawn, and unable to socialise, mate, 

and care for their offspring, compared with attached monkeys (Sadock et al., 2014). Ainsworth 

et al., (1972) went on to develop Bowlby’s theory further by analysing the mother-infant 

relationship in an experimental condition called the strange situation. Ainsworth discovered 

that infant attachment could be classified into three categories: secure, insecure, and 

ambivalent. Disorganised is a fourth category which was added later by Ainsworth’s colleague 

Mary Main (Mooney, 2010).  

The strange situation identified common behaviours related to the four different 

attachment styles (Mooney, 2010). Securely attached children feel confident their primary 

caregiver will respond to cues and provide a safe base, so that they can explore their 

environment. Proximity is a primary goal to ensure comfort and protection if distressed. Secure 

attachment develops when a caregiver is available, responsive, and sensitive (Ainsworth, 

1991). Insecure avoidant children, on the other hand, do not prioritise proximity with a 

caregiver. They display both physical and emotional independence and do not seek comfort 

when distressed. Insecure avoidant children have a caregiver who is withdrawn, unhelpful, and 

unavailable (Ainsworth, 1973). Insecure ambivalent or resistant children display clingy and 



29 

 

dependent type behaviours, but will also reject the caregiver when they try to engage or provide 

comfort. This group of children failed to develop security when in proximity to the caregiver. 

Parenting behaviours are thus said to be inconsistent and do not meet the child’s needs 

(Ainsworth, 1973). Children with a disorganised style of attachment exhibit disorientation such 

as wandering, confused expressions, freezing, undirected movements, and disorganised 

interactions with the caregiver (Main & Solomon, 1990). Parents of infants with disorganised 

attachment are said to be abusive and neglectful, resulting in a paradox being created between 

the child’s secure base and the origin of negative experience (Main & Solomon, 1990). 

Attachment theory provides a framework for understanding the emotional reactions of infants 

and the attachment style of the adult. 

Attachment interactions are characterised by specific behaviours that prompt and 

encourage maternal responsiveness and proximity (Dozier et al., 2001). Infants are born with 

behaviours aimed at getting adult attention. Such behaviours manifest as crying, smiling, eye 

contact, grasping, clinging, and reaching (Prior et al., 2006). Attachment is thought to develop 

in stages, beginning in pregnancy and enduring throughout the lifespan (Klaus & Kennell, 

1976). According to Bowlby (1989), the first three years of life are the most informative 

attachment years. Shaffer and Emerson’s (1964) four-stage model of attachment is commonly 

referred to in the literature and aligns with Bowlby’s four phases of attachment. The asocial 

stage lasts from birth to six weeks old and is when the mother and child orient themselves to 

each other. The infant learns to signal caregivers, who in return learn to identify the baby’s 

cues, respond to its needs and provide comfort. Indiscriminate attachment is the next stage, 

from six weeks to seven months. Here, the mother and infant have established their routine and 

the infant’s sleeping and feeding needs are becoming regulated and predictable. Infants at this 

stage are also developing the skills to show and respond to emotional expression and talking. 



30 

 

At seven to nine months the infant is becoming attached in the specific attachment 

stage. When attachment occurs separation anxiety emerges, where the infant becomes 

increasingly wary of strangers and maintaining proximity to the caregiver becomes a priority. 

The fourth stage is the multiple attachment stage, when the baby is 10 months. This stage 

continues throughout its lifetime. The infant becomes independent and begins to form 

attachment with several individuals, not just limited to their family. Receiving encouragement, 

support, and guidance from the caregiver during this stage is important. By age three, children 

should have developed good social skills, be socially confident, autonomous, and affectionate. 

Based upon the four stages of attachment, milestones are met at certain ages that promote the 

development of a positive internal working model (Bretherton & Munholland, 2008). The 

internal working model sets the child’s expectations about attachment figures, the support they 

can expect to receive during times of stress, and the individual’s interactions with others. The 

internal working model is thought to be the underlying mechanism that shapes personalities 

and determines the types of relationships individuals experience throughout life (Bretherton & 

Munholland, 2008). 

The real-life application of attachment theory sees the role of the mother as fundamental 

to the attachment relationship and process. Attachment literature often refers to the mother-

child relationship, however in contemporary times the caregiver-child relationship has been 

greatly endorsed, recognising the modern-day diversity of the maternal figure (Van den Dries, 

Juffer, van Ijzendoorn, & Bakermans-Kranenburg, 2009; Dozier et al., 2001; Pittman, Keiley, 

Kerpelman, & Vaughn, 2011). Pittman et al. (2011) argue that attachment theory does not 

discriminate between who takes on the role of a mother as long as that person responds to and 

meets the infant’s needs. Although Bowlby’s theory concentrated on the mother-child dyad, 

Bowlby himself conceded that children can attach to multiple caregivers (Bowlby, 1958b). This 

is a contentious issue, with some arguing that bonding for the mother begins during pregnancy, 



31 

 

and is optimised within a biological mother and baby relationship (Mirick & Steenrod, 2016). 

This is because of the intrinsic factors that promote a mother-child connection that evolves 

during pregnancy, as well as the extrinsic factors such as skin to skin contact and breastfeeding, 

which occur in the first few hours after birth (Mirick & Steenrod, 2016). These factors are said 

to contribute to a mother’s ability to bond with a baby, and are developed at birth and through 

interactions with the baby (Klaus & Kennell, 1976). Attachment, on the other hand, is more 

about the baby’s journey, and according to Bowlby (1982) is inherent and innate. Bonding is 

thought to be impeded when a primary caregiver is not the gestational carrier and is incapable 

of performing natural motherly duties such as breastfeeding (Mirick & Steenrod, 2016). Walker 

(2008) disagrees, suggesting that substitute caregivers can bond as effectively as biological 

mothers if they are open to it.  

Substitute caregivers can replace the biological mother and be as successful in 

developing secure attachment bonds with the infant. Walker (2008) argues that for substitute 

caregivers to optimise the opportunities to bond with the infant, their background and personal 

growth history is important. Maternal sensitivity and responsiveness, which are determined by 

the mother’s early childhood experiences and beliefs about parenting, is a major determinant 

of a successful caregiver-child relationship. Dozier et al. (2001) argue that the nature of 

attachment will vary according to the caregiver’s own attachment history, psychopathology, 

and parenting style. Research shows that caregivers who are aware of their own attachment 

history, can identify attachment issues, and are able to work through their issues, are more 

likely to provide the infant with a secure attachment relationship (Lang et al., 2016). Parenting 

styles have also been identified as important to this relationship. Caregivers who experience 

mental health issues tend to display more inconsistent parenting type behaviours, resulting in 

more insecure, disorganised attachments (Lang et al., 2016). Research shows, therefore, that 



32 

 

given the right circumstances, substitute caregivers can provide optimal attachment 

opportunities compared with biological mothers. 

Kinship and Non-Kinship Caregiving and Attachment 

Foster care is one example of when a substitute carer takes on the role of the biological 

mother. Although foster care seems to be a good alternative, whereby infants are protected and 

provided with a safe environment, the separation from their family/whānau and the emotional 

toll this takes on the infant is thought to have a huge impact on their future development 

(Mercer, 2006). There is ongoing international debate as to whether kinship or non-kinship 

caregivers provide the best attachment opportunities, and opinion is divided. Keeping infants 

within their wider family group is thought to be less traumatising compared with placing them 

with complete strangers (Worrall, 2001). Kinship care is also reported to be longer-lasting and 

more stable, which promotes better opportunities to attach, and may encourage important 

contact with the biological parents (Lawler, Koss, Doyle, & Gunnar, 2016; Testa, 2002; 

Vanschoonlandt, Vanderfaeillie, Van Holen, De Maeyer, & Andries, 2012).  

Despite not being the preferred option for substitute care, non-kinship caregivers have 

been shown to provide a more stable, nurturing environment for children (Brown, Bakeman, 

Coles, Platzan, Lynch., 2004). Vanschoonlandt et al. (2012) evaluated the differences between 

kinship and non-kinship placements and found that although behavioural problems are lower 

for children in kinship care, it is not the role of the non-kinship caregiver that impacts 

behaviour, but the number of placements they experience and the trauma they experience 

before they are placed. Rubin et al. (2008) concur, emphasising the increased threat of 

unofficial access to the biological parents, and the parental dysfunction being inherent in other 

family members. The Vanschoonlandt (2012) study also found that foster caregivers could 

develop better relationships with key stakeholders involved in the child’s life, which promoted 

a stronger bond with the infant. In New Zealand, family/whānau caregivers are preferred by 



33 

 

Oranga Tamariki, as stated in the Children, Young Persons, and Their Families Act 1989, that 

“where possible, the family, whānau, hapū, and iwi are responsible for care and protection of 

a child.” This is preferred because of the importance of maintaining continuity and to ensure 

that cultural identity is protected (Ministry of Social Development, 2007). If for any reason the 

child is unable to be placed in the care of whānau, the child should be placed “in an appropriate 

family-like setting, where personal and cultural identity are prioritised” (Children, Young 

Persons, and Their Families Act, 1989). Atwool (2006) contends that non-kinship caregivers 

in New Zealand are competent in establishing relationships that provide plenty of attachment 

opportunities and a secure base. Furthermore, the indefinite nature of placements, as well as 

the many placements a newborn might experience in its first years of life, impact the attachment 

relationship more than the caregiver’s willingness and ability to attach. Moreover, it appears 

that placements with kinship caregivers are fraught with their own issues, which can impact 

the attachment quality and caregiver-child bonding opportunities.  

 Attachment research has identified many factors that can diminish the success of secure 

attachments developing. Much of this information focuses on the substitute caregiver and their 

inability to perform tasks of which only a biological mother is capable. Carrying the baby is 

one such factor. It is argued that the bonding process begins during pregnancy. Grace (1989) 

highlighted the progression of maternal foetal attachment in a longitudinal study that assessed 

a mother’s connection with the baby in the antepartum period. Grace found that a mother’s 

attachment did develop and intensify during different stages of her pregnancy, however the 

study did not determine how this materialised into attachment in the postpartum period. Smith 

and Ellwood (2011) recognised the importance of the perinatal period, suggesting that there 

are biochemical processes in both the mother and infant that enhance bonding prior to and after 

birth. Klaus and Kennell (1976) also discuss the hormones released after birth that promote the 

mother and baby to feel a connection with each other. Dozier et al. (2001) disagree, implying 



34 

 

that research is limited and what is most important is the caregiver’s state of mind, and their 

availability and sensitivity to the infant. Non-biological caregivers who have chosen to care for 

newborns may not have developed the intrinsic motivation to bond, but experience an 

extrinsically based motivation to provide for and nurture, which can be just as advantageous 

(Bick, Dozier, Bernard, Grasso, & Simons, 2013). Furthermore, Bick goes on to highlight the 

association between bonding and the release of oxytocin, and how the release is not exclusively 

experienced by a biological mother, but can take place for a non-biological caregiver as well.  

Attachment theory prioritises feeding time as a prime ritual for attachment interaction, 

suggesting that the quality of interactions during feeding is an important factor in successful 

attachment (Ainsworth et al., 1972; Bowlby, 1982). Feeding time has become the focus of 

much attachment research because of the modern-day diversity of the maternal figure and the 

transformation of breast to bottle feeding. The importance of the intimate interactions during 

feeding, such as eye-to-eye contact, cuddling, smiling, and touching is prioritised instead. A 

great deal of literature proposes that it is these interactions that are essential to attachment 

rather than whether the infant is breast or bottle fed. Smith and Ellwood (2011) disagree, 

arguing that there is a link between breastfeeding, cognitive development, and attachment, 

which is promoted by the biochemical components of breast milk. However, breastfeeding 

research suggests that while breastfeeding does promote greater maternal sensitivity, breast-

fed babies are no better attached compared with bottle-fed babies (Britton et al., 2006). 

Furthermore, the focus should be on the quality of the feeding interactions, which are thought 

to encourage positive brain development and attachment (Wilkinson & Scherl, 2006).  

It has been well documented that multiple placements are a significant factor impacting 

the caregiver-foster child attachment process. The vulnerability of a child increases with every 

new placement. The constant disruption to the infant’s primary caregiving relationship results 

in insecure attachment patterns and behaviour problems in later childhood (Atwool, 2006; 



35 

 

Newton, Litrownik, & Landsverk, 2000). Placement breakdowns become a perpetuating 

problem; breakdowns occur and impact attachment, and the lack of attachment produces 

adverse outcomes such as behaviour problems and, in turn, the behaviour problems are thought 

to cause the placements to break down (Brown & Bednar, 2006; Newton et al., 2000). 

Attachment theory posits that the anguish and distress of losing a primary caregiver can impact 

an infant’s willingness to attach, and can only be resolved if the infant is provided with 

consistent opportunities to attach to alternative caregivers (Bowlby, 1982; Oosterman, 

Schuengel, Wim Slot, Bullens, & Doreleijers, 2007). Oosterman et al. (2007) concur, showing 

in their meta-analysis study of disruptions in foster care that caregivers who are non-responsive 

are at greater risk of placement breakdown, indicating that attachment interactions do 

strengthen bonds and provide greater security to infants.  

There is extensive literature discussing the impact of childhood abuse and trauma on 

attachment patterns (Ainsworth, 1991; Mennen & O'Keefe, 2005). Infants who have been 

exposed to maltreatment are often exposed to unresponsive caregiving, resulting in few to no 

quality attachment interactions (Morton & Browne, 1998). Morton and Browne found that 

maltreated children are less likely to form secure attachment bonds, and are more likely to 

display disorganised/disoriented attachment patterns. Their internal working models are more 

than likely to be cautious of close relationships due to the paradox of mother as abuser. Because 

of the maladjusted internal working schemas these children tend to experience difficulties in 

attaching, and therefore struggle in foster care placements (Mennen & O'Keefe, 2005). Marcus 

(1991) concurs, finding a relationship between the quality of attachment to caregivers and 

positive outcomes. Dozier and Rutter (2008) expand on these findings and highlight the impact 

of maltreatment on the developing brain by showing that maltreatment in the first few weeks 

of life can alter neurobiological development, increasing the risk of attachment disorganisation. 



36 

 

Age is thought to be a significant moderator for attachment security (Van den Dries et 

al., 2009). Several studies show that infants who are uplifted in their first few months of life 

have greater success of secure attachment development compared to children who are uplifted 

after one year of age (Dozier & Rutter, 2008). It is thought that the earlier experiences of 

forming bonds create stronger foundations for core beliefs (Van den Dries et al., 2009). It is 

these core beliefs that influence our thought processes and perceptions, therefore having a more 

powerful impact (Beck, 2011). As attachment stages tell us, attachment begins to consolidate 

around seven to nine months of age, and it is after this period that attachments grow stronger 

(Howe, 2001; Marcus, 1991; Mennen & O’Keefe, 2005; Shaffer & Emerson, 1964). Mercer 

(2006) suggests that infants who have been uplifted before six months of age are not at greater 

risk of experiencing insecure attachment relationships because the attachment bond has not yet 

developed. In addition, Dozier, et al. (2001), suggest that infants who display unsettled 

behaviours in their first week in a new placement are more likely to develop insecure 

attachment patterns. The unsettled behaviours may also interfere with the foster caregiver’s 

opportunity to provide quality attachment opportunities, particularly during feeding time.  

Maternal substance use during pregnancy is also said to influence the attachment 

outcome for infants (Miller, 2016; Tait, 2012). Attachment theory provides a framework that 

helps us understand how emotional and relational development is impacted by prenatal drug 

exposure (Irner, Teasdale, Nielsen, Vedal, & Olofsson, 2014; Parolin & Simonelli, 2016). 

Research shows that infants who have been prenatally exposed to drugs tend to demonstrate 

insecure and disorganised attachment patterns (Bada et al., 2008; Swanson, Beckwith, & 

Howard, 2000). The teratological effects of the substance, maternal characteristics, separation 

from the mother, or the multiple caregivers with whom they are placed in their first year of life 

have all been associated with possible causality (Rodning, Beckwith, & Howard, 1991; 

Swanson et al., 2000). Attachment theory asserts that mothers who use during pregnancy are 



37 

 

more likely to display parenting habits, styles, and interactions that are incongruent with the 

development of secure attachment patterns (Parolin & Simonelli, 2016; Rodning et al., 1991). 

This is thought to be because of the drugs’ effects on the mother’s maternal behaviours, as well 

as the personality traits inherent in a mother who chooses to abuse during pregnancy (Parolin 

& Simonelli, 2016). Emerging research is showing that the teratogen of the substance can be 

mitigated if the infant receives a nurturing, responsive caregiving environment (Bada et al., 

2008; D'Angiulli & Sullivan, 2010).  

Attachment theory emphasises the negative developmental effects of poor attachment 

relationships on a developing child. A lack of attachment interactions in the first year of life is 

said to play an etiological role in the development of psychopathology. Disorders related to 

attachment are said to arise when a child sustains emotional and relational damage, which is 

said to change the neurology of a developing brain, resulting in greater susceptibility to adverse 

mental health outcomes (Atwool, 2006; Sadock et al., 2014; Van den Dries et al., 2009). The 

work of Gunnary and Kertes (as cited in Brodzinsky & Palacios, 2005) shows that poor 

attachment interactions with a primary caregiver can cause a change in the structure and 

function of the brain. This is thought to occur in three major ways: through severe maltreatment 

and malnourishment, lack of stimulation, and neurochemical malformations due to an adverse 

environment. Furthermore, Rees’ (2007) study of childhood attachment shows that neuronal 

plasticity, cognitive development, and regulation of stress responses are all influenced by the 

quality of primary caregiving. In addition to greater risk of psychopathology, 

insecure/disorganised attachment patterns can influence the quality of relationships throughout 

adulthood. Secure attachment promotes more stable, successful relationships without fear of 

rejection or jealousy.  



38 

 

Māori Culture and Attachment Theory 

Many argue that attachment theory can be universally applied, and the fundamental 

concepts are immune from cultural influence. Bowlby’s argument was based upon the idea that 

the phenomenon of survival is universal and inherent in all human beings. Van Ijzendoorn and 

Kroonenberg (1988) disagreed, investigating global attachment patterns across eight countries, 

finding that cultural variations in childrearing do in fact impact the development of attachment. 

Van Ijzendoorn attributed this to how the strange situation protocol was fallible when used 

with other cultures. Moreover, Pryor (2005) critiques the narrowness of the early writings of 

attachment theory and the focus being on the dyadic nature of attachment. Subsequently, 

contemporary thought associates attachment with a wider interpersonal network of people with 

whom attachment can occur (Morelli & Henry, 2013). It is through this contemporary position 

that attachment theory can align with some indigenous traditions about child development and 

child rearing. Māori culture is one such indigenous group that values the importance of 

relationships from a more collective perspective (Marsden & Royal, 2003). 

Te Ao Māori views traditional child-rearing practices holistically, where connections 

are made not only with others but also with extrapersonal phenomena (Marsden & Henare, 

1992; Marsden & Royal, 2003; Mead, 2016). It is the connection to these concepts that is 

fundamental to Māori wellbeing. These concepts weave together to define Māori identity 

(Mead, 2016). Contrary to a western view of identity, the Māori worldview of identity is 

genealogically (whakapapa) based. Mead (2016) discusses how the characteristics of identity 

involve genealogical, spiritual, and kinship attributes. This way of defining identity shows the 

way in which Māori are connected to the rest of the universe. Due to the widely regarded 

Western acceptance of attachment theory as a childhood development model, contemporary 

thinking in New Zealand must impart the fundamentals of tikanga (practices/rules/traditions) 

to attachment theory, to ensure applied appropriateness for Māori (Fleming, 2016).  



39 

 

Unlike Western theories of attachment, traditional Māori tikanga (customs and 

practices) views attachment as more of a collective process. Parenting is an important concept 

that is the responsibility of whānau (family), hapū (subtribe), and iwi (tribe) (Marsden & Royal, 

2003). Whānau is comprised of an extended family group, hapū is usually made up of more 

than one whānau connected through whakapapa (genealogy) and whenua (land), and iwi is 

many hapū groups connected through ancestors and whenua (Fleming, 2016). A child does not 

solely belong to the parents, but to the whānau, hapū, and iwi. Childrearing is the responsibility 

of everyone, not just the parents alone, and pēpi (babies) and tamariki (children) are often raised 

by their Kaumātua (grandparents) (Marsden & Henare, 1992; Marsden & Royal, 2003).  

The Kaumātua role is integral to a child’s development because Kaumātua are viewed 

as the holders of knowledge and can pass the treasures from the ancestors down to the new 

generation (Marsden & Royal, 2003; Mead, 2016). This is an important process, as tamariki 

are considered treasured gifts and are the future of the lineage (Wirihana & Smith, 2014). 

Furthermore, bonding with other members in the whānau occurs from birth, rather than 

Western notions that state that wider attachment occurs in latter childhood (Jenkins & Harte, 

2011). Akin to Western ideals, attachment is achieved through Māori concepts such as 

whakawhānaungatanga (establishing relationships) and tūrangawaewae (the place where we 

belong which can provide safety), with the child developing relationships in a safe and secure 

environment (Royal, 2007; Waiti & Kingi, 2014). 

Attachment theory and Māori beliefs diverge regarding the importance of connections 

for wellbeing being established beyond just interpersonal relationships with others. 

Connections to other phenomena such as whakapapa (lineage), whenua (land) and wairua 

(spirituality) are also paramount (Haenga-Collins & Gibbs, 2015; Jenkins & Harte, 2011). The 

complexities of how these concepts are woven into Māori culture and identity is beyond the 

scope of this thesis topic, but basic definitions are given to provide context. Whakapapa 



40 

 

connects the individual to a wider context involving tribal groupings and geographical regions 

(Wirihana & Smith, 2014). Whenua provides a space for whānau to be together, and is also an 

integral part of the tūrangawaewae process, which connects the individual to a place in which 

they belong. This space provides important connections to ancestors. Furthermore, whenua 

provides the iwi with food and medicines for healing and sustenance, both important in 

wellbeing (Te Ngaruru, 2008). Wairuatanga (spiritual realm) plays an integral role in the Māori 

worldview of wellbeing. It provides protection by connecting people to their ancestors, 

knowledge, the land, and the uni