# Situation: The nurse works in the infant and toddler section of the pediatric ward of a provincial hospital, where a parent or grandparent stays at each child's bedside as a watcher. The nurse reviews her notes on four children admitted within the past 24 hours. Each has a family caregiver at the bedside, and none is seriously ill. Child | Observed behavior 9-month-old | Cries and turns away when a nurse reaches for him; calms in his mother's arms 14-month-old | Goes readily to any adult, rarely looks toward his mother, and shows no distress when she leaves the room 2-year-old | Screams and kicks when his father leaves, then falls asleep hugging his blanket 11-month-old | Crawls off to play with toys, returning often to his grandmother's lap Whose behavior MOST needs further assessment of attachment?

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> subject: Nursing Practice II — Maternal and Child Health Nursing

## 문제

Situation: The nurse works in the infant and toddler section of the pediatric ward of a provincial hospital, where a parent or grandparent stays at each child's bedside as a watcher.

The nurse reviews her notes on four children admitted within the past 24 hours. Each has a family caregiver at the bedside, and none is seriously ill.

Child | Observed behavior
9-month-old | Cries and turns away when a nurse reaches for him; calms in his mother's arms
14-month-old | Goes readily to any adult, rarely looks toward his mother, and shows no distress when she leaves the room
2-year-old | Screams and kicks when his father leaves, then falls asleep hugging his blanket
11-month-old | Crawls off to play with toys, returning often to his grandmother's lap

Whose behavior MOST needs further assessment of attachment?

## 보기

1. The 11-month-old
2. The 14-month-old **✔ 정답**
3. The 9-month-old
4. The 2-year-old

**정답: 2**

## 해설

Stranger anxiety, protest at separation, and returning to the caregiver between bouts of exploration are all signs of healthy attachment at these ages. A young child who goes readily to any adult, does not check back with the parent, and shows no distress at separation shows indiscriminate friendliness. This lack of attachment behavior is a red flag for possible neglect and needs further assessment, even though the child looks calm and easy to handle.

## 심화 해설

Core clinical reasoning

Attachment behavior in infants and toddlers is assessed by observing how the child uses the caregiver as a secure base during exploration, how the child responds to strangers, and how the child reacts to separation and reunion. The 14-month-old who goes readily to any adult, rarely looks toward the mother, and shows no distress when she leaves is demonstrating indiscriminate friendliness, a pattern that is not typical secure attachment and warrants further evaluation [1][4].

Expected attachment behaviors by age

| Child | Observed behavior | Interpretation |
| --- | --- | --- |
| 9-month-old | Cries and turns away from nurse; calms in mother's arms | Stranger anxiety with caregiver as secure base; developmentally appropriate |
| 14-month-old | Goes readily to any adult; no checking with mother; no distress at separation | Indiscriminate friendliness; possible disinhibited social engagement disorder; needs further assessment |
| 2-year-old | Screams and kicks when father leaves; falls asleep hugging blanket | Separation protest with use of a transitional object; expected for age |
| 11-month-old | Crawls off to play; returns often to grandmother's lap | Secure-base behavior; healthy exploration with periodic check-ins |

Why the 14-month-old stands out

Secure attachment does not mean the child never leaves the caregiver. Rather, the child uses the caregiver as a base from which to explore, periodically returning for reassurance, and shows age-appropriate wariness of unfamiliar adults. The 11-month-old demonstrates this well: crawling off to play but returning often to the grandmother's lap is a classic secure-base pattern [1]. The 9-month-old shows stranger anxiety, which typically emerges around 8–10 months and reflects a growing selective attachment. The 2-year-old shows separation protest, which peaks in toddlerhood and is a sign that the attachment relationship is meaningful to the child.

In contrast, the 14-month-old shows a striking absence of these expected behaviors. Going readily to any adult without checking back with the caregiver and showing no distress at separation suggests that the child has not formed a selective, discriminating attachment to the mother. This pattern is described in the literature as indiscriminate friendliness or, when persistent and impairing, disinhibited social engagement disorder [1]. It is distinct from simple insecure attachment and is strongly associated with a history of neglect or inconsistent caregiving [4].

Clinical significance for nursing assessment

A child who appears calm and easy to handle because they do not protest separation may seem less concerning than a child who screams and kicks. However, the absence of attachment behavior is the more significant finding. Indiscriminate friendliness is a red flag for possible neglect or maltreatment and requires further assessment, even when the child appears comfortable and well-regulated. Research indicates that indiscriminate friendliness can persist even after caregiving improves, which means early identification is important for planning appropriate intervention [4].

Watch out! Do not confuse separation anxiety with pathology. Crying, clinging, and protesting when a caregiver leaves are developmentally expected in infants and toddlers. The concerning pattern is the lack of selective attachment, not its intensity.

Key point! In attachment assessment, the nurse observes three dimensions: response to strangers, separation response, and reunion behavior. The child who shows no discrimination between caregiver and stranger across all three dimensions is the one who needs further evaluation [1].

Differentiating attachment patterns

| Pattern | Response to stranger | Separation response | Reunion/check-in behavior | Clinical implication |
| --- | --- | --- | --- | --- |
| Secure attachment | Wary or cautious; may seek caregiver | May protest; distress is expected | Seeks comfort, then returns to play | Healthy; no intervention needed |
| Insecure attachment | Variable; may avoid or resist caregiver | May show minimal or exaggerated distress | May not be soothed by caregiver | Monitor; assess caregiving context |
| Indiscriminate friendliness / DSED | Approaches readily; no reticence | Minimal or no distress | Does not check back; treats all adults similarly | Further assessment for neglect or maltreatment [1][4] |

The 14-month-old fits the third pattern. The behavior is not simply a temperamental difference; it reflects a failure to form a focused attachment to a specific caregiver. In the pediatric ward setting, the nurse should document the observed behavior objectively, note the absence of checking back and separation distress, and communicate the need for a more comprehensive psychosocial and developmental assessment .References (research sources)

- [1]Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment.Research articleZeanah CH, Gleason MM (2015) · DOI: 10.1111/jcpp.12347

- [4]FACTORS ASSOCIATED WITH INDISCRIMINATE FRIENDLINESS IN HIGH-RISK CHILDREN.Research articleLove L, Minnis H, O'connor S (2015) · DOI: 10.1002/imhj.21520

## 임상 시나리오

Attachment Red Flags in Young ChildrenRecognizing when calm behavior masks concern
A child who goes readily to any adult, does not check back with the caregiver, and shows no distress at separation may appear easy to handle but is displaying indiscriminate friendliness. This pattern is a red flag for possible neglect and requires further assessment.

Expected attachment behaviors include stranger anxiety around 6-9 months, separation protest in toddlers, and using the caregiver as a secure base during exploration with periodic returns for reassurance.

CautionDo not mistake a quiet, non-protesting child for a securely attached one. Lack of attachment behavior in a child under 2 years warrants evaluation for disinhibited social engagement disorder or neglect, even without other signs of illness.

## 핵심 개념

- **Secure base** — The caregiver provides a sense of safety from which the child can explore and return for comfort.
- **Stranger anxiety** — Distress or wariness toward unfamiliar people, typically emerging around 6-9 months of age.
- **Separation protest** — Distress when separated from the primary caregiver, a normal developmental response in toddlers.
- **Indiscriminate friendliness** — Lack of expected attachment behavior where the child shows no preference for the caregiver and readily approaches strangers.
- **Transitional object** — An item like a blanket or toy that helps a child manage separation anxiety and self-soothe.

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