1 ATTACHMENT THEORY , SYMBOLIC INTERACTIONISM AND GROUNDED THEORY : ARTICULATING REFERENCE FRAMEWORKS FOR RESEARCH

Objective: to present and reflect on the articulation between the Attachment Theory, Symbolic Interactionism and Grounded Theory in the study of bonding and interaction between caregivers and institutionalized children. Method: the data were collected between April and July 2015 through intensive interviews, structured observation and a field diary, at a shelter institution that welcomes children between zero and eight years old in a city in the South of Brazil. Fifteen caregivers and six children participated in the research. Results: the Attachment Theory and Symbolic Interactionism permitted understanding the implications of the establishment and rupture of bonds and the strategies the caregivers use in this interaction. The Grounded Theory guided the elaboration of the theoretical model “Perceiving the work/care for institutionalized children”. Conclusion: the articulation among the Attachment Theory, Symbolic Interactionism and Grounded Theory demonstrated its consistency for the study developed, contributing to care in the context of children’s shelter. DESCRIPTORS: Child, institutionalized. Caregivers. Interpersonal relations. Qualitative research. Nursing. Grounded theory. TEORIA DO APEGO, INTERACIONISMO SIMBÓLICO E TEORIA FUNDAMENTADA NOS DADOS: ARTICULANDO REFERENCIAIS PARA A PESQUISA


INTRODUCTION
Interaction is the means used for the primary socialization of individuals, playing a fundamental role in human development, as they are born without knowing.Hence, adults will guide children's actions for them to learn how to cope with the situations in their life. 1Children achieve this when they imitate adults, as well as through the penalties and rewards they receive, and also by the words the adults use to identify the world and everything it contains. 1It is through interaction with adults that the children come to know the world around them and socialize with others.
It is through interaction with the attachment figures, usually parents or caregivers, whom the children identify with, that they create their selfimage and their perception of the world.These figures come to play a central role in the evolutionary development of the child's personality, acting in their way of feeling, thinking and acting. 2 Thus, when individuals interact for a period of time, they share a perspective that will lead their view of their experiences. 1Therefore, since their childhood, individuals are influenced to learn a perspective on the world and the things it contains, in order to use it as their point of view.
When children are deprived of family life, because they are at a personal and social risk, they need to be referred to a welcoming institution.The institutionalization of children is a measure used for their protection, according to the Statute of the Child and Adolescent. 3 In most cases, however, it can weaken and expose them, since it can lead to the rupture of the bonds they possess with their families and their social networks and, consequently, cause problems related to physical and emotional development, aggravating their condition even further.][6] In this sense, it is imperative that the professionals responsible for the care of the sheltered children be prepared to offer humanized and integral care in order to favor their full development.For caregivers to be able to effectively perform this care, however, they need to be provided with proper psychological support and qualification, so that they can deal with the various difficulties that arise daily in the context of violence, without despairing or revictimizing the victim with precipitated and unsafe acts. 7n shelters, caregivers take responsibility for caring for children by playing the role of the adult, which is usually represented by the parental figures.In this context, the theoretical framework of Symbolic Interactionism is inserted as a possibility to signify the interactions of the caregiver with the institutionalized child.Drawing a parallel with the concept of attachment, 8 the need for interaction and social stimulation is highlighted with a view to the development of attachment and bonding.
The constitution of the self and the acquisition of symbols are created in the interaction with other individuals, being witnessed first through the actions and words of others, which are a mirror for the perception of one's own existence. 1In that sense, Symbolic Interactionism favors the understanding of the childhood experience, in a wide range of contexts, through "the senses and interactive practices between the child and his/her daily care", 9:918 as well as between the child and the family, caregivers and peers.
:42 In addition, this theory permits understanding child development from the complete dependence of the child to the development of a sense of individuality, self-regulation of affect, selfesteem and social capacity. 10 Based on the above, it can be observed that institutionalization can affect children in different ways, interfering in their development and in their affective bonds, and it is important that caregivers be equipped to receive and assist them. 11Thus, the following guiding question was raised: how can the Attachment Theory, Symbolic Interactionism and Grounded Theory be articulated in the study of bonding and interaction between caregivers and children in the context of a shelter?The objective was to present and reflect on the articulation among the Attachment Theory, Symbolic Interactionism and Grounded Theory in the study of bonding and interaction between caregivers and institutionalized children.
In view of the importance of interaction for the primary socialization and development of individuals, knowing the interactive relationship in the caregiver-child dyad in early childhood, based on the understanding of the caregiver and the observation of the child, can offer important contributions to the care to this small being who has already experience, despite his / her young age, the rupture of the attachment behavior and the bond with the mother.In this perspective, nurses can devise care strategies to intervene and facilitate the bonding, which is that fundamental for the children's growth and development, and for their mental health in adulthood, in view of their proximity to the child population in diverse contexts, such as hospitals, primary health care units and specialized health care services.

METHOD
In this qualitative research, Attachment Theory 8 and Symbolic Interactionism 1 were used as a theoretical framework.In addition, the Grounded Theory (GT) was used as a method, according to Charmaz' perspective. 12e GT focuses on the elaboration of conceptual theory plans through inductive analysis based on the data. 12In the GT, the data constitute the basis and their analysis will establish the concepts.Its goal is to discover what occurs in the environments investigated and what the investigated subjects' life is like.Thus, the data are being constructed through observation, interaction and material collected on the topic or the study environment. 12he research scenario was a shelter institution that receives male and female children from zero to eight years of age, located in a city in the South of the State of Rio Grande do Sul.It is an institution that houses children, referred by the Juvenile Court Judge and Guardianship Council, who cannot remain with their families.Participants in the survey were professionals involved in direct care for children from zero to three years in the morning, afternoon and evening shifts, totaling 15 people, as well as six children from zero to three years, and the sample selection was intentional.This direct care included all the activities carried out by the caregivers with the children which favor physical and visual contact (feeding, bathing, changing diapers, helping to crawl and walk, play and learning activities, comforting the children on the lap, rocking, among others).
The choice of children from zero to three years old and the professionals who develop their care was due to the fact that it is at this stage that attachment behavior and attachment to the main care figure are developed. 8The inclusion criteria in the study were, for the caregivers: work at the institution for at least three months and provide direct care to children from zero to three years sheltered in the institution; and for the children: between 0 and 3 years of age, in the institution for at least one month.Meanwhile, the exclusion criteria for the caregivers were: to belong to the technical team and to be caring for children older than three years; and for the children: to be adopted during the collection period, leaving the shelter.
The data were collected from April to July 2015.Before starting the data collection, the researcher made an approximation visit to the institution, where she got to know the environment and the professionals who worked there, explaining about the research and the procedures to be executed.Data were collected through an intensive interview 12 (guided conversation that permits a detailed analysis of a theme or experience) with caregivers, structured observation of the interaction of each caregiver with each child, that is, an analysis of how the interaction of the dyad (caregiver-child) takes place.The observation occurred in a threemonth monitoring period, observing the interaction of each caregiver with the six children, at different moments of care and leisure.In addition, data were supplemented with information on the history of the children present at the institution, provided by the shelter's technical staff (psychologist, social worker and legal representative) and by the fi eld notes.
The data were recorded and later transcribed for full analysis.Thus, in line with GT, the transcription of the data occurred concomitantly with the initial analysis, so that, with each new interview or observation, they evaluated the information, coding and categorizing them and later returning to the fi eld to continue and complement the data collection.
For the analysis of the data, the initial coding was carried out, followed by the focused coding.The theory emerged from the researcher's refl exive interpretation of the research context. 13Thus, based on the selection of the codes, they elaborated the categories, and the coding defi ned the analytic structure, linking the data collection and the development of the theory. 12garding the ethical premises, Resolution 466 from December 2012 was complied with.A letter of consent was requested from the participating institution and the participants were asked to sign the Free and Informed Consent Form.Approval for the project was obtained from the Ethics Committee through the Brazil Platform, under CAEE 42696915.9.0000.5316and Opinion 1.035.995.

RESULTS
The participants in the survey were 15 female caregivers, aged 22 to 58 years, who completed education from elementary school to higher education.As for the family income, the participants declared gaining two to four minimum wages and the length of experience at the institution ranged from eight months to 12 years.
Based on the analysis, the theoretical model was constructed: Perceiving the work / care for institutionalized children.This model was delimited by three categories and their subcategories, being: Experiencing the impact of reality (Being institutionalized; Getting attached and Letting go); Working with Care (Caring for and Educating; Working with the Unknown; Remaining Hidden; Learning in interaction with the children); and Facing the daily work (Lacking structure and materials; Lacking staff and training; Working as a team).
Attachment and detachment, as can be seen in fi gure 1, are intertwined with all categories and subcategories, being the central link between caregivers and children in the context of the shelter.

DISCUSSION
Based on the theoretical model presented, it can be observed that the central categories Living the impact of reality, Working with care and Facing the daily work, as well as the secondary phenomena contained therein, are articulated around attachment and detachment.Therefore, work / care involving institutionalized children is an activity that is directly related to bonding and attachment between caregivers and children.
The proper development of attachment behavior is imperative for the mental health of humans.There is a strong correlation between a child's attachment pattern and the pattern of maternal care received. 8Therefore, infants need care that meets their psychological and emotional needs, as well as care related to their physical needs. 14In addition, bonding is fostered by emotional manifestations that arise in the affective relations mediated and interpreted by social partners that assign meanings to the child. 15he Attachment Theory and Symbolic Interactionism served as appropriate theoretical frameworks for the elaboration and discussion of the results, as they support all the phenomena presented.Through the Attachment Theory, we were able to understand that Experiencing the impact of reality is permeated by diverse experiences of the establishment and rupture of bonds, generating a cycle that begins in the child's institutionalization and, not always, is broken in the deinstitutionalization, as both the caregiver as the child will sometimes remember the relationship experienced for a long period of time.
:584 The environment known to the child before the institutionalization is the one it is accustomed to, with its family that, even though it does not offer the most adequate conditions for its physical, emotional and social development, is the reality the child knows.Thus, as from the institutionalization, the child goes to live with strange people and with perspectives different from the ones he/she was accustomed to.Therefore, the care provided at the institutions should provide the children with support and guidance, so that the welcoming represents a space where they find not only wellbeing, but where they are also prepared to develop their autonomy and independence. 17henever children are separated unwillingly from the mother figure whom they are attached to, they feel distress, which intensifies when they are placed in a strange environment, under the care of unknown people. 8Thus, institutionalized children are subject to intense emotional exhaustion, especially when adapting to the institution, since this requires the immediate acceptance of habits, schedules and rules that may be very different from what they experienced in the relationship with their family. 18The need for greater constancy in care, leading to a recognition of their individuality" 19:246 is highlighted as one of the main psychological demands of children.Thus, in the rupture with the biological family, the substitute caregiver needs to offer a receptive and stable contact with children, in order to alleviate the traumas generated by maternal deprivation and permit the development of attachment.
A study using Attachment Theory related behavioral problems in late childhood with the roles of early maternal attachment and with the teacher's relationship with the child. 20This indicates that children with avoidant and ambivalent attachments, compared to those with secure attachments, show higher levels of externalization and / or internalization of behaviors.Teacher-child relationships, as well as externalizing and early internalization behaviors, are important ways to indicate that early maternal attachment relationships influence children's late psychological development.The genesis of behavioral problems, related to the disorganization of the bond, does not only result from the unregulated relationship of the mother-child dyad, but also from unfavorable relationships between the teacher and the child. 20here is an important association between the establishment of a pattern of insecure attachment in childhood and the development of depression in adolescence because, in the second, the bonds established in childhood are tested, as the constitution of a new identity happens only through sharing and interiorization processes. 21Thus, the importance of safe attachment to the development of human beings is highlighted, considering that the quality of attachment and attachment influences the emotional, cognitive and social development of children, future adults, which, if raised in more sensitive environments, can become more just and solidary citizens instead of reproducing the culture of violence. 22ymbolic Interactionism showed to be effective to understand the daily interaction between child and caregiver in the experience of the category Working with care, as they create and recreate their perspectives and ways of acting in the world based on their mutual relationships.Thus, the meanings of things are managed and modified through the interpretive process people use to cope with the things they are faced with. 23aregivers organize care according to their experiences and knowledge, adjusting it to the specific needs of each child.Thus, the adult interacts with the environment on the basis of his / her cultural baggage, changing it according to his / her needs as well as those of the child. 24Therefore, it is in the development of work and in the interaction with the child that the caregiver creates his perspectives of care, influencing and being influenced by the coexistence with peers and the children, in the daily socialization.This elaboration and change of perspective can also be observed in the category Facing the daily work, in which the relations with colleagues and the environment directly influence the way in which care is organized and implemented.
In addition, it is in the interaction with the adult that the child starts to adopt his perspectives, the caregivers being a reference for the sheltered children as, based on the care they receive, they start to reproduce it with each other.:25 Thus, one can understand that the meaning of things has to be formed, learned and transmitted through social interaction. 23Hence, in the social interaction with the caregiver and peers, children construct their operational models of the world, constituting a model of relationship, which delimits what will be experienced in future relations. 2he use of the Grounded Theory provided the elaboration of the theoretical model presented here and, through the coding and categorization, a relation could be established among the phenomena and between these and the theoretical framework of the Attachment Theory and Symbolic Interactionism.A study that also used the Grounded Theory to elaborate a theoretical model proved its applicability for this construction and reproduction in scenarios that attend to children with chronic disease.26 The Grounded Theory broadens and improves the knowledge produced in research, proving to be an important method for use in health research.27 Thus, GT is characterized as a valuable method to construct new theories, and "for the construction of a Grounded Theory, it is essential that the researcher has theoretical sensitivity to understand the subtleties of the meanings of the data".28:463 The effectiveness of the articulation between GT and Symbolic Interactionism is also presented in other studies, [29][30] for the construction of theoretical models.There was no previous articulation among GT, Symbolic Interactionism and Attachment Theory though, but only studies that assessed realities based on the Attachment Theory individually.[20][21]31 It is important to note, however, that the Attachment Theory provides a useful model to understand the role of developmental relationships.31 A study points out that the relative lack of research based on the Attachment Theory limits the understanding of the caregiver's relationships with the child, restricting knowledge about child development and making it difficult to create intervention programs and public policies on child development.22 The theoretical model built on bonding and interaction between caregivers and institutionalized children offers contributions to nursing care in the context of children's shelter, demonstrating the importance of inserting nurse practitioners in this scenario.We hope that the theoretical model developed can be applied to other contexts of child shelter as well.It is known, however, that being a process based on the Grounded Theory, no claim is made on being conclusive, being open to further reformulations based on studies that emphasize the work/care for institutionalized children, adding new perspectives to this reality.

CONCLUSION
The articulation between the Attachment Theory and Symbolic Interactionism as theoretical reference frameworks and the Grounded Theory as a method for the study of bonding and interaction between caregivers and institutionalized children proved to be successful, since it permitted the construction of the theoretical model Perceiving the work/care for institutionalized children.
Through this research, we were able to understand the establishment and rupture of bonds between caregivers and children, and the references used were relevant for the construction of the theoretical model, fully corresponding to reach the intended goal.Therefore, we highlight the substantial

Figure 1 -
Figure 1 -Explanatory theoretical model "Perceiving the work/care for institutionalized children", articulating categories and subcategories