Attachment Theory and Research: Implications for Orphaned and Vulnerable Children’s (OVC) Alternative Care Provisions and Practice in Ethiopia

A substantial number of children become orphan and vulnerable and thus end up in different alternative childcare provisions such as institutionalization and adoption each year in Ethiopia. Effective practice of care and protection of children in general and those of orphaned and vulnerable children in particular requires a strong theoretical and evidence-based knowledge base, a framework that encompasses developmental processes and outcomes, both adaptive and maladaptive, which facilitates planning, decision-making and executions related to OVC alternative care provisions as a whole, and institutionalization and adoption in particular. Such desired knowledge enhances policy-makers’ and practitioners’ insight into the positive and negative impacts of family dynamics on children’s short-and long-term development. The author claims that Attachment theory and research provide policy-makers and practitioners with just such a framework. Specifically, the author argues that attachment theory and research equip policy-makers and practitioners with a working knowledge of key ingredients necessary for effective planning and implementation of alternative care provisions for OVC that spans assessing eligibility for institutionalization and adoption through placement and evaluation of their effectiveness. Attachment research, on the hand, provides them with empirical evidences, which in turn, enable them to make informed decisions related to alternative care provisions to the OVC. This article presents a brief overview of attachment theory, including the development of secure and insecure attachments, and associated lifespan developmental outcomes to show the relevance of the theory to Orphaned and Vulnerable Children (OVC) care provisions and practices. It then gives a summarized review of attachment research. Finally, the paper tries to draw implications deemed applicable to OVC care provisions and practices in Ethiopia?

Orphaned usually refers to a child under the age of 18 years (or 15 years in some countries) whose mother (maternal orphan) or father (Paternal orphan) or both (double orphan) are dead; vulnerable children are defined as those whose safety, well-being and development are, for various reasons, threatened (Haile, 2008).  OVC combines orphaned and vulnerable children; it is used to describe those children who are at higher risk of facing increased negative health and developmental outcomes compared to an “average” child in their respective society (Haile, 2008) and who are eligible for alternative childcare provisions such as institutionalization, domestic adoption, inter-country adoption, and other community-based alternatives. A substantial number of children become orphan or vulnerable and end up in other alternative childcare provisions such as institutionalization and adoption each year in Ethiopia. The exact number of Orphaned and Vulnerable Children (OVC) in Ethiopia is lacking.  But there is growing evidence that   the country stands first in terms of the number of OVC it contributes to the world (Haile, 2008; Selman, 2009) Approximately, about 13 percent of children (4.6 million children) in the country have lost one or both of their parents for various reasons (Haile, 2008; Selman, 2009).  Ethiopia also stands forefront in sending children to the U.S.A. for inter-country adoptions from Africa [1]. for example, Ethiopia has contributed as larger as 67% to the children sent to the U.S.A from African countries for inter-country adoptions between 1996 and 2009(Davis, 2011). Ethiopia’s policy frameworks and legal instruments at different levels of government recognize and recommend foster care home placement, institutionalization, domestic adoption, international adoptions and other possibilities as alternative care provisions for OVC and they are widely practiced. The effectiveness of such alternative child-care practices in ensuring these children’s overall development is, however, largely dependent on the strength of policy-makers’ and practitioners’ theoretical and empirical knowledge base of child developmental processes and outcomes. Hence, policy and decision-makers and practitioners who are in charge of planning and executing these alternative child care practices for OVC need to have a strong empirical and theoretical knowledge of child development that encompasses both adaptive and maladaptive child developmental processes and outcomes. Such desired knowledge enhances their   insight into the positive and negative impacts of family dynamics on children’s short- and long-term development and aid and facilitate the planning, execution, and evaluation of such alternative childcare facilities and practices. As whole, the effective practice of OVC alternative cares deadly requires a strong theoretical and evidence-based knowledge of child development on part of policy and decision makers as well as practitioners and implementers. One such evidence-based theory that   they need to add to their toolkit which provides them with the essential framework for understanding the impact of early social and emotional relationships on cognitive-affective structures used by the child to construct views of the world, self, and others across the lifespan is John Bowlby’s ethological attachment theory [2-3]. Empirical research this theory has generated since its formulation in the second half the 20th century is also equally important for policy-makers and professionals working with the OVC. This paper therefore sets out to give an overview of the theory and the research evidences it has originated, highlighting its relevance to alternative care and services to OVC and eventually draw and highlight implications and recommendations for practice in context.

An Overview of the Evolvement of Attachment Theory

Although it originated from the seminal work of John Bowlby, Attachment Theory in psychology is said to be a joint work of John Bowlby and Mary Ainsworth [4]. John Bowlby formulated the basic tenets of the theory by drawing concepts from ethology, psychoanalysis, and developmental psychology by 1940s through early 1960s, [5] and refined and expanded it over the subsequent years and decades. Mary Ainsworth contributed to the theory by introducing her innovative methodology that made the empirical testing of attachment theory possible, by empirically testing the theory and giving it new direction and shape it has taken today. Although it originated from the seminal work of John Bowlby, Attachment Theory in psychology is said to be a joint work of John Bowlby and Mary Ainsworth. John Bowlby formulated the basic tenets of the theory by drawing concepts from ethology, psychoanalysis, and developmental psychology by 1940s through early 1960s and refined and expanded it over the subsequent years and decades. Mary Ainsworth contributed to the theory by introducing her innovative methodology that made the empirical testing of attachment theory possible, by empirically testing the theory and giving it new direction and shape it has taken today. In fact, a number of other theorists and researchers have contributed to expand and polish the theory to its present shape and status. Among others, Mary Ainsworth has been, and remains, instrumental in the development of attachment theory by devising her innovative methodology to empirically test the theory , sketching out the different styles of attachment herself, and inspiring further empirical research into the issue. As  Seroufe and others [6] note, Bowlby’s attachment theory is a theory of psychopathology and of normal development  because it contains clear and specific propositions regarding the role of early experience in developmental psychopathology, the importance of ongoing context, and the nature of the developmental process underlying pathology and normal development.

Major Propositions of Attachment Theory

The first basic tenet of attachment theory is that human’s attachment behaviour has an evolutionary basis since it maximizes and ensures the survival of those who have it. In other words, attachment behaviour system is prewired in both infants and caregivers; both are pre-programmed to form such attachment because it does have adaptation and survival functions for it ensures the survival of the infant and by doing so it ensures the perpetuation of human species. Human infants possess instinctual behaviours that signal that they need closeness and crying, smiling, cooing, and babbling are some examples of such innate tendencies. Infants are born with many of such behaviours and others develop overtime. In the same vein caregivers, usually mothers are prewired to respond to the signals because such attachment behaviour systems provide the infant with the basic needs and emotional security that it needs to survive and ultimately enable it to adapt to the demands of environment.  Responding to and nurturing one’s dependent young offspring on part of the mother or mother-figure also appears to be biological or instinctual tendency and moral obligation since it meant ensuring the survival of the offspring and perpetuation of one’s species.  Therefore, attachment is universal to all humans; it is not race or culture-specific the attachment relationship also takes into account the emotional aspects of infant-mother relationships. Berghaus (2011) explains how patterns of attachment and internal working models are constructed from early child-caregiver interactions as follows, As the infant engages in attachment behaviours with the caregiver, the infant experiences either responsiveness, rejection, or some combination of both. Eventually, the infant learns to predict caregiver responses based on actual experience. Those infants who most often experience responsiveness become securely attached; those infants who most often experience rejection become avoidant; and those infants who experience an unpredictable combination of both responsiveness and rejection become anxious and ambivalent. These experiences become transformed into the child’s internal working model of relational expectations. The internal working model carries the person’s expectations for all attachment relationships into the future, and remains generally stable unless altered by significant new experiences (p.6) Berghaus (2011) underscores that the importance of the caregiver’s characteristics in promoting either secure attachment or insecure one. In other words, caregiver’s reaction to the attachment behaviours (e.g. smiling, crying, cooing....) the infant engages in with them determines the type of attachment to be established.  Accordingly, infants who   experience responsiveness consistently from their caregivers are most likely to become securely attached while those who experience unpredictable or inconsistent combination of responsiveness and rejection are at increased risk of becoming insecurely attached. These early experiences of infant-caregiver interactions transform into what is referred to as Internal Working Model (IWM); secure type of attachment transforms into positive IWM whereas insecure attachment becomes transformed into negative IWM. IWM is a representation of an individual’s beliefs and expectations of self and others in a relationship; it carries the person’s beliefs and expectations of self and others in all current and future attachment relationships. Once established IWM is likely to persist; it remains generally stable across the lifespan though it is subject to alteration or change under special conditions, especially if the person experiences significant new interactions and relationships. Internal working models are thought to develop, at least in part, from interactions with important attachment figures and, once formed, are presumed to guide social interaction and emotion regulations in childhood and across the lifespan. Four early childhood attachment styles are recurrent in the literature.  In fact, based on their early experiences with their caregivers’ infants fall in either securely attached or insecurely attached category [7,8].In general, literature suggests that attachment security in a mother-infant relationship is dependent on her availability and appropriate responsiveness to the infant. Once established, the security of the infant-mother/caregiver relationship is highly stable over time. In addition, research suggests that attachment security predicts other aspects of a child's development such as social competence, or problem solving [9]. Attachment theorists including John Bowlby accept the possibility of multiple attachments; that is the infant may be able to form selective and hierarchical attachments to a number of persons [10]. Infants can form multiple attachments with multiple persons, but attachments are ranked and generally mother-infant attachment is primary; it is, thus, hierarchical; attachment is about a close and usually affectionate relationship, and its impact lasts from cradle to grave; it is, therefore, enduring and long lasting.

Measuring Attachment     

Before discussing these four attachment styles, however, an overview of ‘how to assess attachment’ appears to be mandatory since understanding the former may be difficult without knowledge of the latter. One of the most commonly used techniques in assessing attachment style or determining the quality of attachment is that of using the “strange situation”. This assessment strategy was first developed and put into use to study attachment among Ugandan infants by Mary Ainsworth. In using the “strange situation”, the practitioner or researcher sets up a situation whereby the parent, infant and a stranger are present in the same room furnished by play materials. The parent is then cued to leave the room at a particular time and the infant is left in the presence of the stranger. At this point, the researcher observes and records the behavioral responses of the infant to the stranger, the departure of the mother and her return [11]. The overall, experimentation takes 20-30 minutes. The Attachment Q-sort or (AQS) is another assessment strategy that has been used to classify children outside the “strange situation” as either being securely, avoidantly or ambivalently attached. This method was designed by Mary Ainsworth to systematically measure the child’s level of attachment in a more natural setting (i.e. the home environment). In using the AQS, two raters rate the infant under assessment on indicators of secure or insecure attachment and the mother and the father can perform the rating at home or  at any other natural environment. The advantage of this strategy over the “Strange Situation” is that it is more flexible in that parents or guardians can be used to rate the infant. Another advantage of AQS is that it is performed in natural environment of the infant as opposed to the “Strange Situation” which appears to be artificial as its name implies.  Another additional method that may be used to assess a child’s style of attachment is the Attachment History Questionnaire (AHQ). Again, this instrument allows the researcher flexibility in the study of attachment. Since questionnaire can be completed by the primary caregiver of the child and since it allows assessment of attachment styles in natural environment of the infant it has been shown to be both reliable and valid measure of attachment patterns of infants and children. 

Types of Attachment Styles and Behaviors

Attachment researchers have been endeavouring to categorize infants into different categories on the basis of their attachments with their primary caregiver(s) and study them longitudinally to figure out the long-term impacts of such early attachments. In fact, Mary Ainsworth is the forerunner scholar in the endeavour of classifying infants into categories based on their attachment with their care giver. Mary Ainsworth and subsequent researchers alike propose two broad categories of infants- securely attached infants and insecurely attached infants. The next few paragraphs elaborate on these two categories of infants. Securely Attached Infants: Secure infants explore readily in the presence of the primary caregiver, are anxious in the presence of the stranger, are distressed by their caregiver’s departure and brief absence, rapidly seek contact with the caregiver following a brief period of separation, and are reassured by renewed contact. This pattern of attachment develops in the context of consistent, sensitive and responsive child-primary caregiver interactions. Children in this category perceive themselves as worthy, others as available, helpful and reliable and the environment as challenging but manageable with support. In time of stress, children in this category are able to respond with both affect and cognition and thus elicit a supportive and timely response [12]. Insecurely Attached Infants:  within the broader “insecurely attached category” there are three sub-categories. Some infants, who are usually made less anxious by separation, do not automatically seek proximity with the caregiver on her return following separation and may show no preference for the caregiver over the stranger; these infants are designated ‘Anxious/Avoidant’. This pattern of attachment develops in the context of unresponsive and rejecting child-caregiver interactions. Children in this category perceive themselves as an unworthy, others as unavailable and hurtful and the environment as threatening and stressful. They become self-reliant at a much earlier stage and learn to shut down attachment behaviours in order to avoid experiences of rejection. This might be due to deactivation and over-regulation of affective responses and amplification of cognitive strategies which, in turn, might have resulted from negative early child-attachment figure interactions and relationships. A second category of the insecurely attached infants, the ‘Anxious/Resistant’ infant manifests impoverished exploration and play, tend to be highly distressed by separation from the caregiver, but have great difficulty in settling after reunion showing struggling, stiffness, or continued crying, or fuss in a passive way. The caregiver’s presence or attempt at comforting fails to offer reassurance and their anxiety and anger appears to interfere with their attempts to derive comfort through proximity. This pattern of attachment develops as a result of inconsistent, unreliable and, at times intrusive, responses from the attachment figure. Children in this category are uncertain about the worthiness of themselves; they perceive others as unreliable, un-bearing, and insensitive.  Moreover, they tend to experience environment as unpredictable and chaotic. Amplification and under-regulation of affective responses to maintain proximity with the attachment figure precludes them from achieving mature self-regulation. Helplessness, resentment, and manipulativeness all characterize children in this category.A fourth group of infants appear to exhibit a range of seemingly undirected behavioural responses giving the impression of disorganisation and disorientation. Infants who manifest freezing, handclapping, head-banging, and the wish to escape from the situation even in the presence of the caregiver are referred to as ‘Disorganised/Disoriented’ (Main, Kaplan, & Cassidy 1985). It is generally held that for such infants the caregiver has served as a source of fear and of reassurance, thus the arousal of the attachment behavioural system produces strong conflicting motivations. In fact, this category is added to the classical ABC tripartite classifications later by Main and Solomon in 1990. It develops as a result of early interactions with frightening and /or frightened primary caregiver or parents. Disorganized attachment has been consistently linked to children’s experiences of prolonged or repeated separation from the caregiver. Van Ijzendoorn and others estimate that about 80% of infants and children from abusive homes show disorganized attachment. Another meta-analytic review by Van Ijzendoorn, Schuengel, and Bakermans-Kranenburg (1999) showed that disorganized attachment was also found with high frequency in infants of alcoholics or depressed mothers and in infants from families with high marital conflict. Feeney, Passmore and Peterson (2007) showed, with their longitudinal study that compared adoptees and non-adoptees, that insecurity was higher for adoptees and those reporting negative childhood relationships with parents.

Children’s Attachment Styles and Associated Short- and Long-term Adaptive and Maladaptive Development

George and West [13] and Van Ijzendoorn, characterize attachment not only as “a major developmental milestone” in the child’s life but also as an issue that   remains important throughout the lifespan. While secure attachment has consistently been linked to adaptive life-course developmental outcomes, childhood insecure attachment has frequently been found to have been associated with a number of lifespan maladaptive developmental outcomes. Research suggests that early adverse experiences such as insecure attachment affect children‘s neuro-cognitive development leading to lower intelligence. The attainment of complex brain development, which encompasses a balanced combination of brain differentiation and integration, is heavily dependent on early child-caregiver interactions [14]. further argues that secure attachments facilitate the development of such complex states (differentiation and integration) in the brain. In contrast, lack of secure attachment impedes the development of complex states in brain namely differentiation and integration thereby leading to lower intelligence and adaptability. Overall, patterns of insecure attachment that might have resulted from early caregiver’s irresponsiveness and inconsistency, privation, deprivation, and other family adversities is consistently linked to lifespan maladaptive developmental outcomes spanning lower intelligence to marital maladjustment. Points summarized in the next paragraph are unrelenting developmental maladjustments that are presumed to originate from the three early childhood insecure attachment patterns. First John Bowlby, the originator of the attachment theory, formulated maternal deprivation hypothesis which states that the continual disruption of attachment between infant and its primary caregiver could result in long-term cognitive, social, and emotional difficulties on part of the infant. In particular, delinquency, reduced intelligence, increased aggression, depression, and affectionless psychopathy have been deemed as long-term consequences of maternal deprivation. Second, adolescents with history of avoidant insecure attachment present as sullen and withdrawn with intermittent outbursts of rage. Peer relationships tend to be superficial, and aggressive behavior may be triggered in close relationships because past experience has taught them that they cannot trust others, especially those close to them [15]. Adults with this pattern of attachment have been characterized as dismissive, placing little value on relationships [16]. Third, by adolescence those with a history of ambivalent/resistant attachment are likely to engage in intense and explosive relationships with attachment figures, [17]. They may desperately want relationships with peers and significant others; but due to their fear of rejection and abandonment they may also drive others away. Adults with this pattern remain preoccupied with relationships and often enmeshed in on-going conflict. Fourth, disorganized or disoriented attachment has been portrayed as an outstanding category in terms of its prevalence and its associations with negative health and developmental outcomes. Research indicates that significant problems in childhood and later life are most frequently linked with this pattern. By adolescence, significantly increased rates of psychopathology and violent crime have been found in longitudinal studies of children classified as disorganized in infancy. In adulthood this pattern has been described as unresolved/ disorganized [18]. Generally speaking, insecure attachment patterns that are presumed to establish from early negative infant-caregiver interactions and relations (or attachment-figure) tend to persist [19]; McClellan & Killeen, [20] and have been associated with impaired cognitive development and socio-emotional maladjustment across the lifespan (Ma, 2006). In contrast, a growing number of evidence shows that there is a strong tie between secure attachment and resilience. Resilience is the capacity to recover from the adverse effects of earlier experiences; it is an ability   to re-bounce back regardless of the presence of adverse antecedents. The tie between attachment and resilience is that securely attached infants are found to be resilient later in life and persist in the face of even marked life stressors. Resilience is a quality that exists at multiple levels of developmental systems (i.e. individual, family, community) and secure attachment is a quality that resides in an individual and helps them to spring back even in challenging situations of life later in life. The avoidant and ambivalent patterns are adaptive and demonstrate a degree of resilience in less-than-optimal circumstances, allowing children to manage relationships and emotions. Children with a disorganized attachment are the most vulnerable, lacking a coherent strategy for managing relationships, feelings or experience.

An Overview of Legal and Policy Frameworks for Alternative Cares for OVC

As pointed out earlier, ideally children are eligible for placement in alternative cares such as foster care homes, institutions, and adoptions when they are able to qualify as orphaned (children under 15 or 18 who lost a parent or both parents) and vulnerable (children at higher risk for their safety, well-being and development due to various reasons). In practice, however, not all orphaned and vulnerable children are placed in alternative cares. In some instances, children who do not qualify for placement in alternative care services can be placed. Arranging children, especially for inter-country (or international) adoption has become a source of income for intermediary individuals and agencies. Some parents or guardians may also wrongly consider inter-country adoption as a golden opportunity for the children and for themselves as well; in extreme cases they may see inter-country adoption as an investment with apparent return. These and other misconceptions may permit the production of false documents and testimonials and let ineligible children end up in inter-country adoptions.  Some critics of international adoption have already begun to characterize the process as “a widespread corruptions and abuse” and have called for restrictive rules and regulations characterize international adoption as something that operates under market mechanism and call for reform in international adoption services. Ethiopia is a signatory to UNCRC and Ethiopian government policies permit both domestic and inter-country adoptions. Civil and Family Codes of the country are the two major national legislations that govern adoptions. Ministry of Lab our and Social Affairs (Molise) and Ministry of Women, Children, and Youth Affairs (Mowry) are government bodies responsible for approval of adoptions. For example, the 1996 Development and Social Welfare Policy document   by the Molise stresses   the implementation of all international and regional conventions and legal instruments concerning the rights of children which Ethiopia had already endorsed and ratified. Specifically, the policy clearly stipulates how the peculiar needs of OVC can be met. The Policy (Article 5.1.7) emphasizes the creation of   conditions conducive enough to enable the OVC to get the assistance they need to be self-sufficient and productive citizens. Furthermore, the policy declares that “all efforts shall be made to provide protection against child abuse and neglect” (Article 5.1.10). Majority of the Ethiopian OVC end up in inter-country adoptions and only few are adopted domestically (UN, 2009) even though the MoWCYA claims that inter-country adoption is the last option to resort to and UNCRC’s (Article 21b) declaration that international adoption (inter-country) should be a subsequent choice when all other family care alternatives have exhaustively been explored at a national level.  Some Policy makers and professionals claim that international adoption is an attempt to reduce institutionalization of OVC but evidence contradicts their claim. For example, conclude that rather than to reduce the number of children in institutional care international adoptions contribute to the continuation of institutional care and the resulting harm to children. In Ethiopia’s reality the larger public and other concerned organizations and individuals have begun to unequivocally express their trepidation that inter-country (or international) adoption has become sources of income for some individuals and organizations working with children. Therefore, there are indications that inter-country adoption has become a ploy for child trafficking and even child trade or “child export” as some professionals and child right activists call it.

Implications

Attachment theory and research can offer a multitude of implications that can dictate policy makers and practitioners in designing and implementing productive and effective alternative cares for OVC. In this section, an attempt has been made to figure out and expound some implications out of Attachment theory and research so that all stake holders of OVC are able to make use of them to uphold OVC rights and their best interests. Attachment can be seen as a developmental outcome of early experiences and as a source of influence on later development as well. Thus, attachment theory is a lifespan approach since it would view problematic issues with children, adolescents and adults as stemming from attachment deficiencies in early life. In contrast secure attachment is seen as an asset or protective factor against problematic issues across the lifespan. In other words, individuals with history of insecure attachment are at risk for cognitive and psychosocial mal-adaptations later in life. But those with history of secure attachment are likely to be resilient and invulnerable to mal-adaptations in all echelons of life across the lifespan. While insecure attachment style is a likely risk factor for unhealthy development throughout lifetime, secure attachment is an immunity that protects or at least buffers such unhealthy development. In close connection, early attachment style tends to be stable across the lifetime; it is subject to change only under special conditions. Therefore, these conditions should be taken in to account in designing and implementing alternative care services for OVC. Before placing a child in alternative care facility, the child’s attachment status should be assessed as objectively as possible. Optimal and suitable alternative care is then chosen   based on the child’s attachment history. Attachment researchers have devised several strategies for assessing attachment and they have already been touched upon above. One point that policy makers and practitioners need to bear in mind is that any alternative care facility for OVC must be able to promote the development of secure attachment, minimize the development of insecure attachment and allow those with negative internal working model to rework it. Alternative care placement is not a lifesaving practice limited to providing the OVC with food and shelter. Rather, it is a practice aimed at producing productive and responsible citizens. Attachment tends to run in families. Technically termed as an Intergenerational Transmission of Attachment (ITA), this hypothesis states that parents with history of insecure attachment are much more likely than those with no such history to have insecurely attached children. Another hypothesis closely related to ITA is that parents with history of child abuse are at risk for abusing their own children themselves and child abuse is a marked   risk factor for insecure attachment. This implies the requirement for rigorous and objective assessment of the potential adoptive parent(s). That is the potential adoptive parents’ suitability assessment should go beyond the surface socio-demographic characteristics such physical health, age, income, childlessness, etc. Their childhood history should be assessed and potential risk factors for insecure attachment on part of the child should be identified and remedied beforehand.  Attachment theory and research offer us a variety of strategies for assessing adult attachment and readers are advised to consult literature on this subject. Of all roles parents play in the lives of their children, their roles as an attachment figure is one of the most important in predicting child’s later social and emotional outcome .Therefore, in assessing the suitability of potential adoptive parent(s) the question “are the potential adoptive parents able to play their role of attachment figure?” should be adequately addressed and prioritized over other issues such as income, education, age, etc.

In many situations, OVC’s alternative care provisions may lack constancy. That is children may move from one alternative care facility to another. For example, children may be placed first in foster care homes, and then moved to orphanage institution and finally end up in international or domestic adoption. Attachment theory and research have suggested that in situations of multiple foster placements, neglect or institutionalization, children may develop disorders of nonattachment [21]. Children with disorders of non-attachment may not be able to form attachment after all and therefore may be prone to later lifetime social and emotional maladjustment. The implication here is therefore multiple placements, neglect or institutionalization must be avoided or at least reduced.  Attachment theory and research also suggests that lengthy institutionalization and foster home placement prior to adoption compromises children’s secure attachment and adjustment. For example, using 56 Romanian orphaned children (3-5 years old) adopted in Ontario, Canada, demonstrated that children who had experienced less than 6 month of institutional care had better outcomes than the rest on developmental measures. In another study, among adopted children, time spent in an institution had negative impact on the onset of externalizing and internalizing problems. Attachment theory and research also tells us that children who were adopted at younger age are most likely to establish secure attachment with adoptive parents and adjust well than those adopted later even when the adoption is interracial or inter-country. A recent study conducted in Spain has shown that children adopted after three years of age presented attentional problems. The implication herein is lengthy institutional and foster home placement prior to adoption should be avoided. In addition, as much as possible, adoption should take place at younger age for children adopted at younger age, perhaps at 2 or earlier, are most likely to establish secure attachment and adjust well compared to late adopted children. OVC as group have many characteristics in common but we cannot afford to ignore the individuality and uniqueness of each child; each child has her own unique characteristics and traits.  Therefore, all placements, custody, and long-term care planning and decisions should be individualized for the child’s best interest and should maximize the healing aspects of the care provisions and practices. These planning, decisions, and executions should be based in part on a comprehensive assessment and periodic reassessment of the child and adoptive parents by professionals who are experts in child development (e.g., pediatrician, psychiatrist, or psychologist) [22-24].

Recommendations

Based on the key implications highlighted in the preceding paragraphs the following important and more specific points should guide policy makers’ and practitioners’ activities related to OVC alternative care and service provisions:

·     Biological parenthood does not necessarily confer the desire or ability to care for a child adequately. Adoptive parents can have the desire or ability to care for children adequately but not all adoptive parents possess such quality. Therefore, suitability of potential adoptive parents should be assessed thoroughly and holistically.

·  Consistent, responsive and supportive nurturing by primary caregivers is crucial to early brain growth and to the physical, emotional, and developmental needs of children; it is also equally crucial to rework and repair previous insecure attachments and negative internal working models.

· Children need continuity, consistency, and predictability from their caregiver. Multiple placements are injurious; lengthy institutionalization before adoption and late adoption can compromise children’s ability to adapt to adoptive parents and environment.

·  Attachment styles and developmental level of the child are key factors in their adjustment to environmental and internal stresses. Hence, policy makers and implementers need to give due emphasis to OVC’s attachment history and developmental level in planning and executing alternative care facilities for the OVC.

·  Child development and care professionals can play a constructive role in the assessment, referral and treatment of children who were abused, neglected, or abandoned before placement in any OVC facility… any damage including insecure attachment and related problems should be remedied before foster care placement, institutionalization, or adoption.

·   Policy makers and implementers in charge of OVC need to make sure that caregivers and facilities

·    give the child plenty of love and attention;

·    are consistent in loving, stimulating, and disciplining the children;

·    stimulate the child through exposure to developmentally appropriate holding, conversation, reading, music, and toys;

·  expose the child to opportunities to improve language via direct voice and face-to-face contact; and

·   Match the environment to the child’s disposition

· Adoptive parents or caregivers in charge should be given reasonable assistance and opportunity to maintain their family, while the present and future best interests of the child should determine what is appropriate and what is not.

·  A child’s attachment history and sense of time should guide the pace of decision-making.

· OVC alternative care provisions and foster care placements should always maximize the healing aspects of respective facility and be based on the needs of the child.

·  Foster care placement with relatives should be based on a careful assessment of the needs of the child and of the ability of the kinship care to meet those needs. As with all foster care placements, kinship care must be supported and supervised adequately.

·    Foster care placement with relatives and domestic adoptions should be prioritized over international adoptions especially for children with history of lengthy institutionalization and insecure attachment, older children, children with disability, and other disadvantaged children

OVC care provision and practice is not a firefighting enterprise; it requires careful planning, decision, and execution. Policy and decision makers and implementers in charge of OVC care provision need to have adequate theoretical and evidence-based knowledge of child development and underlying contextual factors so as to discharge their responsibility effectively. Attachment theory and research is presumed to equip them with such desired theoretical and evidence-based knowledge. Policy/decision makers and implementers in charge of OVC in Ethiopia are advised to familiarize themselves with attachment theory and research to plan productive OVC care provisions and uphold orphaned and vulnerable children’s rights and interest. This paper has provided an overview of attachment theory and research and drawn some implications and recommendations for OVC care provisions taking Ethiopia’s context into account. Professionals in Ethiopia, who work with OVC, are summoned to capitalize on the implications and recommendations drawn and make use of them to discharge the responsibility bestowed to them as effectively as possible.

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