People can develop difficulties with food for a number of reasons, but it is clear that some young people with severe attachment difficulties cope with self and interpersonal difficulties by employing a range of self-destructive behaviours, including disordered eating. Working with this group is difficult and requires some specialist intervention, but there are also a few basic principles that can help.
Crucial principles
• No one chooses to have disordered eating, although the child can seem very attached to theirs. Usually an individual would want to give up their disordered eating if they knew how. Attempts to help can be frightening, because the disordered eating has some advantages
• The disordered eating serves a purpose. Resistance to change and resistance to help are part of the condition, and do not mean that your child is being deliberately difficult, rather it reflects their fears of giving up something that helps with other problematic areas of life.
• Poor self-esteem can be a crucial underlying issue
• There is no quick and easy solution
Fundamentals of management
• Try not to blame the child for her disordered eating
• Accept the child is in distress
• There is no single correct way of helping, but the whole team around the child need to identify and support strategies for working with the disordered eating, and all need to consistently apply them. Finding everyone working together in harmony can provide the child the confidence she needs to overcome her disorder
• The things you do to help need time to work. Be consistent, persistent and repetitive
• Try not to lose sight of the healthy and good things about the child. Get a full and complete picture of her strengths. Try to do the normal things the child enjoys
• Try to separate the disordered eating from the person. This difficulty does not make them a bad person. It’s a bad thing that is happening to a good person
• Away from meals, try to focus on your child’s feelings. Show her that you can acknowledge and accept them. Offer warmth, comfort and reassurance
In cases of anorexia
In cases of anorexia and similar conditions, it’s as if the child has two inner voices. The “anorexic” voice telling her that she is “fat, ugly and stupid” and the “healthy voice” telling her she is “ill, thin and should eat” The first voice is experienced by everyone as louder and more insistent. Try to focus on the healthy voice along the following lines:
I know how strong the voice is that tells you, you are fat and shouldn’t eat; how sometimes it torments you and at others it seems to be your friend. It must be confusing and frightening for you. But I want to speak to the healthy part of you, so I’m not going to talk to the part of you that torments you in that way
Wednesday 28 September 2011
Thursday 26 May 2011
Are care leavers resilient enough for the huge task they face?
Are care leavers resilient enough for the huge task they face? One answer is “yes”; some young people leave care and establish themselves satisfactorily in adult life and thrive in the face of life’s ups and downs. But I imagine we all know young people who face a very different reality; who struggle to live well or cope. Comparing most outcomes for these young people to the general population makes a gloomy picture: more likely to be in prison or hospital, to be pregnant early, to have their own children in care, to misuse substances, to be victims of crime, to be homeless.
All this is often used to show how poorly the care system does for the young people that to care well for is its sole ‘raison-d’etre, although of course it shows no such thing. What it does show is that kids with difficult beginnings have the odds stacked against them throughout life. To know whether the care system helps or not (I suspect that it does sometimes, and doesn’t others) you would need to compare young people in care with a similar group of young people not in care. And that can never be done, because if you found such a group of children you would have to act, to intervene, to bring them the safeguarding and services that the care system brings their Looked After peers.
But, without trying to evaluate the work we do through the use of ill-matched comparison groups, I suspect none of us would deny the “life stacked against them” s experiences of care leavers. Now that’s a big topic, so I’m only going to look at part of it here, that part we call “resilience”.
Resilience can simply be defined as they ability to thrive in adverse circumstances – bouncebackability is a good word for it. We often think of it as a set of personal attributes or characteristics, but Daniel and Wessel suggest that this quality is best thought of from an ecological perspective. An ecological model of resilience says that this ability to bounce back is woven from aspects both of the person and their environment. I like that way of thinking, and the ideas expressed here follow from it.
So, resilience is in part the individual and in part their environment. Let’s return to care leavers. A substantial number of young people come into care with complex, multiple and enduring needs. These needs, which frequently include difficulties forming, sustaining and trusting close relationships, are often poorly understood and contribute to multiple placements which further disrupt the child’s over all functioning. Many are criminalized and given up on; their pathway to adult difficulties strengthened by a system that turns its back on their needs in favour of cheaper alternatives. 50 placements by age 11 is not that uncommon, but even a smaller number is a trail of rejection and failure that is internalized by the child, who nearly always feels that a placement that has ended is their fault. Some get more help than this, a placement is able to meet their needs, to “hold onto” them, to keep them in mind and promote a pathway to recovery, to help them develop many of the individual skills and characteristics that form part of resilience: self-mastery, self-regulation, problem-solving, self-awareness, healthy self-esteem, settled identity, talents & interests, positive values, social competence…the list goes on. And yet, even with this remarkable list, the young person is still at risk of not being resilient enough; however many personal attributes we have, we need stuff outside us, ecological stuff, to be resilient, and here, once again, careleavers are disadvantaged.
The first ecological layer is family. Individuals who have close and supportive ties with families, or with people to whom they belong, are more likely to thrive in adverse circumstances. Of course this is true; supportive families and good friends help each other when they can, and they provide comfort and nurture at times of stress and distress; a safe haven to fly to when times are hard. For many, this safe haven is established in interaction with caring caregivers in their early development, for others it is acquired through enough care later, including stability, working through relational difficulties, solving problems, being valued and belonging. Without it where do you go when it all gets too much? 50 placements by age 18 is not so uncommon…and children that did not have this early, with complex and enduring needs, get good at keeping it away later
The outer ecological layer is community. Again this is disrupted, both by the system and by the way the child copes with their complex, multiple and enduring difficulties. Even if they have succeeded in placement and been stable, and put down roots, they are increasingly likely to be forced back to the risky world they have temporarily escaped. And once they are 18, the resources all but dry up.
I’ve worked with these children and young people for over twenty-two years. I’m interested in therapeutic working, and believe I have contributed to the growth of the personal characteristics of resilience for many individuals. I also believe that I have helped them find a safe haven in good relationships with caregivers and with friends, and I’ve worked hard to support the growth of community networks. And I know I am not alone, staff I have worked with, and other individuals and organizations, work effectively to promote recovery from poor early beginnings, to work, as we say, therapeutically. But society must also accept its role and recognize that the needs of individuals who have come from difficult beings are complex and enduring; its not their fault, they didn’t choose to be neglect or abused as a child, and if they need external support after care they should have it; it takes time to build resilience and autonomy, and prisons, hospitals and homeless hostels are full of people who were given neither the time or the support to do so.
All this is often used to show how poorly the care system does for the young people that to care well for is its sole ‘raison-d’etre, although of course it shows no such thing. What it does show is that kids with difficult beginnings have the odds stacked against them throughout life. To know whether the care system helps or not (I suspect that it does sometimes, and doesn’t others) you would need to compare young people in care with a similar group of young people not in care. And that can never be done, because if you found such a group of children you would have to act, to intervene, to bring them the safeguarding and services that the care system brings their Looked After peers.
But, without trying to evaluate the work we do through the use of ill-matched comparison groups, I suspect none of us would deny the “life stacked against them” s experiences of care leavers. Now that’s a big topic, so I’m only going to look at part of it here, that part we call “resilience”.
Resilience can simply be defined as they ability to thrive in adverse circumstances – bouncebackability is a good word for it. We often think of it as a set of personal attributes or characteristics, but Daniel and Wessel suggest that this quality is best thought of from an ecological perspective. An ecological model of resilience says that this ability to bounce back is woven from aspects both of the person and their environment. I like that way of thinking, and the ideas expressed here follow from it.
So, resilience is in part the individual and in part their environment. Let’s return to care leavers. A substantial number of young people come into care with complex, multiple and enduring needs. These needs, which frequently include difficulties forming, sustaining and trusting close relationships, are often poorly understood and contribute to multiple placements which further disrupt the child’s over all functioning. Many are criminalized and given up on; their pathway to adult difficulties strengthened by a system that turns its back on their needs in favour of cheaper alternatives. 50 placements by age 11 is not that uncommon, but even a smaller number is a trail of rejection and failure that is internalized by the child, who nearly always feels that a placement that has ended is their fault. Some get more help than this, a placement is able to meet their needs, to “hold onto” them, to keep them in mind and promote a pathway to recovery, to help them develop many of the individual skills and characteristics that form part of resilience: self-mastery, self-regulation, problem-solving, self-awareness, healthy self-esteem, settled identity, talents & interests, positive values, social competence…the list goes on. And yet, even with this remarkable list, the young person is still at risk of not being resilient enough; however many personal attributes we have, we need stuff outside us, ecological stuff, to be resilient, and here, once again, careleavers are disadvantaged.
The first ecological layer is family. Individuals who have close and supportive ties with families, or with people to whom they belong, are more likely to thrive in adverse circumstances. Of course this is true; supportive families and good friends help each other when they can, and they provide comfort and nurture at times of stress and distress; a safe haven to fly to when times are hard. For many, this safe haven is established in interaction with caring caregivers in their early development, for others it is acquired through enough care later, including stability, working through relational difficulties, solving problems, being valued and belonging. Without it where do you go when it all gets too much? 50 placements by age 18 is not so uncommon…and children that did not have this early, with complex and enduring needs, get good at keeping it away later
The outer ecological layer is community. Again this is disrupted, both by the system and by the way the child copes with their complex, multiple and enduring difficulties. Even if they have succeeded in placement and been stable, and put down roots, they are increasingly likely to be forced back to the risky world they have temporarily escaped. And once they are 18, the resources all but dry up.
I’ve worked with these children and young people for over twenty-two years. I’m interested in therapeutic working, and believe I have contributed to the growth of the personal characteristics of resilience for many individuals. I also believe that I have helped them find a safe haven in good relationships with caregivers and with friends, and I’ve worked hard to support the growth of community networks. And I know I am not alone, staff I have worked with, and other individuals and organizations, work effectively to promote recovery from poor early beginnings, to work, as we say, therapeutically. But society must also accept its role and recognize that the needs of individuals who have come from difficult beings are complex and enduring; its not their fault, they didn’t choose to be neglect or abused as a child, and if they need external support after care they should have it; it takes time to build resilience and autonomy, and prisons, hospitals and homeless hostels are full of people who were given neither the time or the support to do so.
Tuesday 3 May 2011
Managing behaviours – not what a child does, by why they do it
Behaviours have a purpose and serve a need. When a child has unwanted behaviours we need to prioritise: changing long-held coping strategies and unwanted habits is hard, takes time, and requires helpful and supportive relationships. Children will probably not change their behaviours just because we want them to. They need opportunity to develop new, more adaptive skills, and to model acceptable behaviour.
Don’t forget that a child does not need to perform a behaviour to model it, it is enough that behaviour is observed for the child to incorporate it into their repertoire. The “modelling ratio” is probably 100:1, that is, a child needs to see a new behaviour consistently (up to 100 times) in order to incorporate the new behaviour into their repertoire, but only needs to see an existing behaviour once in order to have it confirmed that this is a satisfactory way of acting. Suddenly, being a “good role model” doesn’t seem so easy; how many little bits of negative social behaviour do we bring to our own interactions with kids, with colleagues, with parents, with strangers? It is also worth remembering that modelling is a more powerful influence than conditioning; that is, a child learns more about how to behave from how they experience significant others around them behaving toward them, or see them acting toward others (children and adults) than attempts to change behaviour through rewards or sanctions (conditioning).
It is important to recognize that behaviours (good and bad) happen in a context, and that the context in which a person acts is at least as important in deciding their behaviour as their personal characteristics and learnt behaviours. Hardly seems possible does it, but true none the less. Therefore, in considering how to help a child develop alternatives to unwanted behaviour, we must take account of the context in which the behaviour occurs.
The first step towards change is to create a hierarchy of behaviours to focus on – it cannot be possible to change all behaviours at once. The maximum number is three, and if these behaviours are coping strategies, they will need to be replaced with more adaptive ways of coping that work for the child.
In order to encourage change you need reliable data; what does the child do, where do they do it, what else is going on, etc. A data grid is useful, for each target beahviour:
• Date
• Time
• Duration
• Antecedents – what was going on before?
• Accurate description of behaviour
• Describe what happened as a result of the behaviour
• List all the people this was a problem for
• Explain for each why it was a problem
• What is the child’s perception of what happened - you may need to get this information later
• Were they able to identify a goal they had in mind when they behaved like this?
• What function (purpose) do you think the behaviour served?
These data need to be analysed in order to plan effective interventions. We should always ask more about why a child does something than about what they do.
Don’t forget that a child does not need to perform a behaviour to model it, it is enough that behaviour is observed for the child to incorporate it into their repertoire. The “modelling ratio” is probably 100:1, that is, a child needs to see a new behaviour consistently (up to 100 times) in order to incorporate the new behaviour into their repertoire, but only needs to see an existing behaviour once in order to have it confirmed that this is a satisfactory way of acting. Suddenly, being a “good role model” doesn’t seem so easy; how many little bits of negative social behaviour do we bring to our own interactions with kids, with colleagues, with parents, with strangers? It is also worth remembering that modelling is a more powerful influence than conditioning; that is, a child learns more about how to behave from how they experience significant others around them behaving toward them, or see them acting toward others (children and adults) than attempts to change behaviour through rewards or sanctions (conditioning).
It is important to recognize that behaviours (good and bad) happen in a context, and that the context in which a person acts is at least as important in deciding their behaviour as their personal characteristics and learnt behaviours. Hardly seems possible does it, but true none the less. Therefore, in considering how to help a child develop alternatives to unwanted behaviour, we must take account of the context in which the behaviour occurs.
The first step towards change is to create a hierarchy of behaviours to focus on – it cannot be possible to change all behaviours at once. The maximum number is three, and if these behaviours are coping strategies, they will need to be replaced with more adaptive ways of coping that work for the child.
In order to encourage change you need reliable data; what does the child do, where do they do it, what else is going on, etc. A data grid is useful, for each target beahviour:
• Date
• Time
• Duration
• Antecedents – what was going on before?
• Accurate description of behaviour
• Describe what happened as a result of the behaviour
• List all the people this was a problem for
• Explain for each why it was a problem
• What is the child’s perception of what happened - you may need to get this information later
• Were they able to identify a goal they had in mind when they behaved like this?
• What function (purpose) do you think the behaviour served?
These data need to be analysed in order to plan effective interventions. We should always ask more about why a child does something than about what they do.
Saturday 12 February 2011
Transference and countertransference
As concepts, transference and counter transference essentially derive from Freud. Although empirical human behavioural sciences have moved on from many of his ideas, the usefulness of these two concepts to clinicians remains, and they are seen as essential elements in the therapeutic relationships; elements that need to be recognized, understood, and worked with. I think most psychotherapists would say that we need to be thoroughly trained in working with transference / countertransference, and I would not disagree that that would be useful; however, that is not likely to happen for residential staff and foster carers, and yet they will go through this process many times in their work. So it seems useful, in the spirit of working therapeutically, rather than being a therapist, for front line staff and their managers to have affirm grasp of the processes involved.
The other aspect of the therapeutic relationship is the therapeutic alliance. The therapeutic alliance is the rational relationship that exists between the child and the therapeutic worker; it is the mutual understanding that the one needs help, support and assistance and that it is the other’s role to provide it. This may be an overt and uncomplicated therapeutic relationship, but in many cases it is complicated by “unconscious” expectations of close relationships that have grown out of past trauma, relational failure, and unresolved separation and loss.
Transference involves the projection of a mental representation of a previous experience onto the present, transferring an inappropriate aspect of a past relationship onto the other person in the therapeutic relationship. (It is not inappropriate to mistrust someone who let you down in the past and therefore to mistrust someone who lets you down now, but it is inappropriate to assume someone will let you down in the here and now when they have never done so).
Transference is much more likely when the child / young person is under real or imagined threat, and when they have rigid and inflexible personality traits (e.g in individuals who show signs of borderline personality disorder).
Transference needs managing, or it will wreck the therapeutic relationship:
• Recognize the importance of the relationship to the child / young person(this happens when we get close)
• Maintain professional boundaries, and be aware of professional ways of working and responding so we can recognize when we begin to act in response to transference
• Not being pulled into complementary roles that reinforce transference
• Reflecting and interpreting these experiences for the child / young person at a pace and level that is bearable for them.
Countertransference is the response elicited in the worker by the child / young person’s communication of their distressing experiences through transference, and includes the feelings that are evoked in the worker (e.g. helplessness, hostility, fear). Countertransference can be a useful guide to the child’s experiences (e.g. being helpless, rejection, threat). Melanie Klein developed the idea of countertransference by recognizing that it could flow in both directions. I think you see this very strongly when placements are under pressure: adults may feel overwhelmed and needing a break (transferring fear and failure on the child / young person), and this elicits feelings of blame and rejection in the child (countertransference). Staff can feel very responsible for the troubling feelings engendered by the work, and become defensive, whereas understanding that these feelings may have been elicited in them by the distressed child, and can be seen as a window on their inner world, can reduce feelings of being overwhelmed and/or blamed, and therefore reduce the need to be defensive.
Countertransference also needs to be worked with:
• Countertransference is more easily recognized when it is out of character with how we would usually feel or respond
• It requires reflection: a reasonable level of self-awareness, a questioning attitude towards our own feelings and motives, recognition that we all have “blind spots”
• Understanding that we are all affected by the child / young person’s distress, although in different ways,
• Recognizing that they will have strong feelings for us (both negative and positive)
One of the most useful helping resources is the team; sharing our countertransference experiences to clarify what the child / young person projects onto each of us, and unpicking what these feelings tell us about the child / young person’s experience in the here and now. Another useful resource is external consultancy, both for the team and for individuals. It is important that understanding of the internal changes implicit in these processes are matched to individual’s own typical self-defence style; that is if an individual tends to become enmeshed in a child / young person’s difficulties, they need help to process feeling of rejection, but if they tend to dismiss these difficulties as behavioural, they need help in understanding the link between the behaviour and early trauma.
The other aspect of the therapeutic relationship is the therapeutic alliance. The therapeutic alliance is the rational relationship that exists between the child and the therapeutic worker; it is the mutual understanding that the one needs help, support and assistance and that it is the other’s role to provide it. This may be an overt and uncomplicated therapeutic relationship, but in many cases it is complicated by “unconscious” expectations of close relationships that have grown out of past trauma, relational failure, and unresolved separation and loss.
Transference involves the projection of a mental representation of a previous experience onto the present, transferring an inappropriate aspect of a past relationship onto the other person in the therapeutic relationship. (It is not inappropriate to mistrust someone who let you down in the past and therefore to mistrust someone who lets you down now, but it is inappropriate to assume someone will let you down in the here and now when they have never done so).
Transference is much more likely when the child / young person is under real or imagined threat, and when they have rigid and inflexible personality traits (e.g in individuals who show signs of borderline personality disorder).
Transference needs managing, or it will wreck the therapeutic relationship:
• Recognize the importance of the relationship to the child / young person(this happens when we get close)
• Maintain professional boundaries, and be aware of professional ways of working and responding so we can recognize when we begin to act in response to transference
• Not being pulled into complementary roles that reinforce transference
• Reflecting and interpreting these experiences for the child / young person at a pace and level that is bearable for them.
Countertransference is the response elicited in the worker by the child / young person’s communication of their distressing experiences through transference, and includes the feelings that are evoked in the worker (e.g. helplessness, hostility, fear). Countertransference can be a useful guide to the child’s experiences (e.g. being helpless, rejection, threat). Melanie Klein developed the idea of countertransference by recognizing that it could flow in both directions. I think you see this very strongly when placements are under pressure: adults may feel overwhelmed and needing a break (transferring fear and failure on the child / young person), and this elicits feelings of blame and rejection in the child (countertransference). Staff can feel very responsible for the troubling feelings engendered by the work, and become defensive, whereas understanding that these feelings may have been elicited in them by the distressed child, and can be seen as a window on their inner world, can reduce feelings of being overwhelmed and/or blamed, and therefore reduce the need to be defensive.
Countertransference also needs to be worked with:
• Countertransference is more easily recognized when it is out of character with how we would usually feel or respond
• It requires reflection: a reasonable level of self-awareness, a questioning attitude towards our own feelings and motives, recognition that we all have “blind spots”
• Understanding that we are all affected by the child / young person’s distress, although in different ways,
• Recognizing that they will have strong feelings for us (both negative and positive)
One of the most useful helping resources is the team; sharing our countertransference experiences to clarify what the child / young person projects onto each of us, and unpicking what these feelings tell us about the child / young person’s experience in the here and now. Another useful resource is external consultancy, both for the team and for individuals. It is important that understanding of the internal changes implicit in these processes are matched to individual’s own typical self-defence style; that is if an individual tends to become enmeshed in a child / young person’s difficulties, they need help to process feeling of rejection, but if they tend to dismiss these difficulties as behavioural, they need help in understanding the link between the behaviour and early trauma.
Friday 11 February 2011
Placement stability and attachments: two strands in a single braid
Many Looked-After Children and Young People have difficulties around their early attachments that cast long shadows over the present. At some level, all children living away from home will have experienced loss and separation, but a significant number will have developed insecure attachments that make this loss and separation more difficult to handle. Estimates vary, but between 25 and 40% of children across the country may be insecurely attached. However, experience tells us that Looked-After Children are more frequently anxious in their attachments than the general population.
Looking after children with attachment difficulties is demanding work. Their very difficulties make relationships difficult, and placements are at risk through impoverished relational abilities. However, what such children need most is stability. Stability requires commitment from commissioners and expertise from providers. Without these, placements are tenuous, uncertain and unstable, which creates further difficulties for the child in developing secure relationships. Coming into care is often about safeguarding, and rightly so, but, when a child has had a difficult early life, being in care should also be about recovery and opportunity.
Children possess an attachment system that is activated as soon as an internal or external threat appears; if their own resources are insufficient to eliminate the danger, attachment behaviours are triggered. These feelings, expectations and behaviours are directed towards an attachment figure, who is selected by the child on the basis of proximity and availability. This is the child’s first experience of an intimate relationship; it balances safety and exploration and over the first years of life, as the developing child becomes more aware of the inner world of others, it becomes a reciprocal relationship. The degree to which the child learns to trust the relationship is dependent on the quality of the attachment figures responses to the child’s need for safety and exploration. Good enough care promotes secure relationships, but constant failures in caregiving leave the child feeling anxious and insecure.
Attachment theory is a theory of human development across the life span. As we become older the nature of our attachment relationships change, the circumstances that elicit attachment behaviours alter, our attachment behaviours mature, but the need for this primary bond remains. Initially, attachment security can be seen as a function of the relationship between the child and the attachment figure. However, as the child develops, these early encounters become internalized, and the attachment pattern established early in life becomes increasingly a property of the child themselves. The good news is that these patterns are not unchangeable; rather they represent developmental pathways probable unless there is a change in caregiving. However, although attachment style is amenable to change, the way that attachment is organized has been shown to be highly stable over time.
Attachment organization represents a coherent way for the child to achieve the maximum bearable proximity to their attachment figure at times of threat and maintain the maximum bearable distance for exploration. However, some children are so dazed and confused by their early experiences that that they cannot form a coherent strategy, and are seen as disorganized and disoriented.
Disorganized attachment is not uncommon, but is more widespread in families with low social economic status. Van Ijzendoorn et al (1999) suggest that as many as 15 – 25% of children have disorganized attachment, but that this rises to 43% in families with substance abuse, and 48% in maltreating families. This, along with observational data, suggests that many socially excluded children have a disorganized pattern of attachment.
Allen et al (1996) have shown substantial links between adolescent attachment organization and mental health. They found in a clinical sample that preoccupied adolescents were highly sensitive to parental responses: if met with parenting responses that were passive or enmeshed, they showed internalizing symptoms such as depression and anxiety, but with rejecting or ignoring parental responses, preoccupied adolescents show externalizing responses, becoming involved in delinquency, substance misuse and promiscuity. Encouragingly, positive friendships reduced delinquency.
In contrast, dismissing adolescents were less influenced by parental reciprocation; they coped by distracting themselves and others from their attachment cues through substance abuse and conduct problems.
Kiriakardis (2006) investigated the backgrounds and beliefs of 152 young offenders, using the Parental Bonding Instrument (Parker et al 1979) and self-reports of beliefs and attitudes around reoffending. He found that maternal over-protection correlated with both intentions to reoffend and positive views of offending behaviour, whereas, offenders who recalled high levels of parental care evaluated their offending behaviour more negatively.
Good care in a planned therapeutic environment can be therapeutic, but multiple placements and changing caregiving styles can further disorganize the child’s inner world. Not all children who come into care have the same degree of difficulties. Clough et al (2006) suggest a framework:
Tier 1: Relatively simple & straightforward needs: Placements may be stable because they are relatively low cost.
Tier 2: Deep rooted, complex needs: Difficulties often emerge with adolescence, putting strain on possible fairly stable placements, however, placement moves may disorganize attachments.
Tier 3: Extensive, complex & enduring needs: This group of children / young people require expertise, support, long-term commitment, and they may require support beyond childhood.
Whilst short-term, timely intervention may be sufficient for the first group of children, for those in the other groups only carefully planned and skilfully delivered caregiving (which exceeds normal good parenting) is needed (Cameron & Maginn, (2009). Those with enduring needs may well require levels of support that are not available after leaving care, so drift into adult mental health or prisons.
But recovery is possible. A critical idea is the planned environment; by working with attachment in mind, caregivers provide a secure base for the child to explore relationships in the here and now, promoting cognitive restructuring, and safely containing and expressing emotions (Taylor, 2010).
The child’s experience of being in care should be one of recovery, but we have to ask critical questions about the quality of a service that for many children seems to replicate the disorganizing factors of their early experiences.
Recommendations
Support therapeutic approaches that keep attachment in mind in social settings and through individual psychotherapy
Develop a two-strand, integrated approach: a therapeutic social milieu and individual work
Interventions should take account of how to maintain the child/young person’s safe relationships
References:
Allen, J.P., Hauser, S.T., and Borman-Spurrell, E. (1996). Attachment theory as a framework for understanding sequelae of severe adolescent psychopathology: An 11-year follow-up study. Journal of Clinical Psychology. 64(2): 254-263.
Bogaerts, S., Vanheule, S., & Declercq, F. (2005). Recalled parental bonding, adult attachment style, and personality disorders in child molesters: A comparative study. Journal of Forensic Psychiatry and Psychology, 16(3), 445-458.
Cameron, R. J., & Maginn. C. (2009). Achieving Positive Outcomes for Children in Care. Sage: London.
Clough, R. Bullock, R. & Ward, A. (2006) What Works in Residential Child Care. London: NCERCC & National Children’s Bureau.
Haapsalo, J., Puupponen, M., and Crittenden, P. M. (1999). Victim to victimizer: The psychology of isomorphism in a case of a recidivist pedophile in Finland. Journal of Child Sexual Abuse, 7, 97-115.
Kiriakardis, S.P. (2006). Perceived parental care and supervision: a relation with cognitive representations of future offending in a sample of young offenders. International Journal of Offender Therapy and Comparative Criminology. 50 (2): 187-203.
Liska, A.E., and Reed, M.D. (1985). Ties to conventional institutions and delinquency: estimating reciprocal effects. American Sociological Review. 50(4): 547-560.
Sampson, R. J. & Laub J. H. (2005). A Life-Course View of the Development of Crime. Annals of the American Academy of Politics and Social Science, 602, 12-45.
Smallbone, S.W., and Dadds, M.R. (1998). Childhood attachment and adult attachment in incarcerated adult male sex offenders. Journal of Interpersonal Violence. 13: 555-573.
Taylor, C.J. (2010). A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishing.
van Ijzendoorn, M. H., Schuengel, C. & Bakers-Kranenberg, M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae, Development and Psychopathology 11, 225-246.
Looking after children with attachment difficulties is demanding work. Their very difficulties make relationships difficult, and placements are at risk through impoverished relational abilities. However, what such children need most is stability. Stability requires commitment from commissioners and expertise from providers. Without these, placements are tenuous, uncertain and unstable, which creates further difficulties for the child in developing secure relationships. Coming into care is often about safeguarding, and rightly so, but, when a child has had a difficult early life, being in care should also be about recovery and opportunity.
Children possess an attachment system that is activated as soon as an internal or external threat appears; if their own resources are insufficient to eliminate the danger, attachment behaviours are triggered. These feelings, expectations and behaviours are directed towards an attachment figure, who is selected by the child on the basis of proximity and availability. This is the child’s first experience of an intimate relationship; it balances safety and exploration and over the first years of life, as the developing child becomes more aware of the inner world of others, it becomes a reciprocal relationship. The degree to which the child learns to trust the relationship is dependent on the quality of the attachment figures responses to the child’s need for safety and exploration. Good enough care promotes secure relationships, but constant failures in caregiving leave the child feeling anxious and insecure.
Attachment theory is a theory of human development across the life span. As we become older the nature of our attachment relationships change, the circumstances that elicit attachment behaviours alter, our attachment behaviours mature, but the need for this primary bond remains. Initially, attachment security can be seen as a function of the relationship between the child and the attachment figure. However, as the child develops, these early encounters become internalized, and the attachment pattern established early in life becomes increasingly a property of the child themselves. The good news is that these patterns are not unchangeable; rather they represent developmental pathways probable unless there is a change in caregiving. However, although attachment style is amenable to change, the way that attachment is organized has been shown to be highly stable over time.
Attachment organization represents a coherent way for the child to achieve the maximum bearable proximity to their attachment figure at times of threat and maintain the maximum bearable distance for exploration. However, some children are so dazed and confused by their early experiences that that they cannot form a coherent strategy, and are seen as disorganized and disoriented.
Disorganized attachment is not uncommon, but is more widespread in families with low social economic status. Van Ijzendoorn et al (1999) suggest that as many as 15 – 25% of children have disorganized attachment, but that this rises to 43% in families with substance abuse, and 48% in maltreating families. This, along with observational data, suggests that many socially excluded children have a disorganized pattern of attachment.
Allen et al (1996) have shown substantial links between adolescent attachment organization and mental health. They found in a clinical sample that preoccupied adolescents were highly sensitive to parental responses: if met with parenting responses that were passive or enmeshed, they showed internalizing symptoms such as depression and anxiety, but with rejecting or ignoring parental responses, preoccupied adolescents show externalizing responses, becoming involved in delinquency, substance misuse and promiscuity. Encouragingly, positive friendships reduced delinquency.
In contrast, dismissing adolescents were less influenced by parental reciprocation; they coped by distracting themselves and others from their attachment cues through substance abuse and conduct problems.
Kiriakardis (2006) investigated the backgrounds and beliefs of 152 young offenders, using the Parental Bonding Instrument (Parker et al 1979) and self-reports of beliefs and attitudes around reoffending. He found that maternal over-protection correlated with both intentions to reoffend and positive views of offending behaviour, whereas, offenders who recalled high levels of parental care evaluated their offending behaviour more negatively.
Good care in a planned therapeutic environment can be therapeutic, but multiple placements and changing caregiving styles can further disorganize the child’s inner world. Not all children who come into care have the same degree of difficulties. Clough et al (2006) suggest a framework:
Tier 1: Relatively simple & straightforward needs: Placements may be stable because they are relatively low cost.
Tier 2: Deep rooted, complex needs: Difficulties often emerge with adolescence, putting strain on possible fairly stable placements, however, placement moves may disorganize attachments.
Tier 3: Extensive, complex & enduring needs: This group of children / young people require expertise, support, long-term commitment, and they may require support beyond childhood.
Whilst short-term, timely intervention may be sufficient for the first group of children, for those in the other groups only carefully planned and skilfully delivered caregiving (which exceeds normal good parenting) is needed (Cameron & Maginn, (2009). Those with enduring needs may well require levels of support that are not available after leaving care, so drift into adult mental health or prisons.
But recovery is possible. A critical idea is the planned environment; by working with attachment in mind, caregivers provide a secure base for the child to explore relationships in the here and now, promoting cognitive restructuring, and safely containing and expressing emotions (Taylor, 2010).
The child’s experience of being in care should be one of recovery, but we have to ask critical questions about the quality of a service that for many children seems to replicate the disorganizing factors of their early experiences.
Recommendations
Support therapeutic approaches that keep attachment in mind in social settings and through individual psychotherapy
Develop a two-strand, integrated approach: a therapeutic social milieu and individual work
Interventions should take account of how to maintain the child/young person’s safe relationships
References:
Allen, J.P., Hauser, S.T., and Borman-Spurrell, E. (1996). Attachment theory as a framework for understanding sequelae of severe adolescent psychopathology: An 11-year follow-up study. Journal of Clinical Psychology. 64(2): 254-263.
Bogaerts, S., Vanheule, S., & Declercq, F. (2005). Recalled parental bonding, adult attachment style, and personality disorders in child molesters: A comparative study. Journal of Forensic Psychiatry and Psychology, 16(3), 445-458.
Cameron, R. J., & Maginn. C. (2009). Achieving Positive Outcomes for Children in Care. Sage: London.
Clough, R. Bullock, R. & Ward, A. (2006) What Works in Residential Child Care. London: NCERCC & National Children’s Bureau.
Haapsalo, J., Puupponen, M., and Crittenden, P. M. (1999). Victim to victimizer: The psychology of isomorphism in a case of a recidivist pedophile in Finland. Journal of Child Sexual Abuse, 7, 97-115.
Kiriakardis, S.P. (2006). Perceived parental care and supervision: a relation with cognitive representations of future offending in a sample of young offenders. International Journal of Offender Therapy and Comparative Criminology. 50 (2): 187-203.
Liska, A.E., and Reed, M.D. (1985). Ties to conventional institutions and delinquency: estimating reciprocal effects. American Sociological Review. 50(4): 547-560.
Sampson, R. J. & Laub J. H. (2005). A Life-Course View of the Development of Crime. Annals of the American Academy of Politics and Social Science, 602, 12-45.
Smallbone, S.W., and Dadds, M.R. (1998). Childhood attachment and adult attachment in incarcerated adult male sex offenders. Journal of Interpersonal Violence. 13: 555-573.
Taylor, C.J. (2010). A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishing.
van Ijzendoorn, M. H., Schuengel, C. & Bakers-Kranenberg, M. J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae, Development and Psychopathology 11, 225-246.
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