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.

 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

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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