davidshemmings

On 26 April 2014 Zoe Williams published an article in The Guardian entitled ‘Is misused neuroscience defining early years and child protection policy’? Some of you reading this will know that our son-in-law died last November following a brain tumour, so it was difficult for me to join in the discussion. But I felt that some of the contributions on social media ceased being a ‘debate’, fairly early on. My fear is that this is now starting to happen with attachment theory and research. Consequently, I’d like to make my views on using attachment-based principles in child protection work as clear as I can.

Over the past four years Yvonne and I have worked with nearly 3000 practitioners to help deepen their knowledge of attachment-based principles. We always stress how it can really help families stay together, whenever possible, as part of relationship-based practice. Here are seven principles that inform the work.

Seven Principles for using attachment-based approaches in child protection work

1. The main aim of using attachment-based principles is to help and support families stay together, whenever it is feasible to do so.
2. People can usually change and there is, as yet, no firm evidence that there are critical periods of a child’s development after which change is impossible, except in the most extreme forms of maltreatment – although the longer we leave things, the harder it is to overcome abuse and neglect.
3. It is preferable to think of disorganised attachment behaviour, not disorganised attachment per se. (These behaviours are temporary and fleeting, not an attachment ‘style’). The behaviours are not predictive of maltreatment: they indicate that additional questions need to be posed urgently, as the child may already have experienced ‘fear without solution’.
4. Practitioners need to make sure that they are not constrained by ‘confirmation bias’: forming a viewpoint too quickly and then only taking account of information which confirms it – we need an ‘open mind, but not an empty head’.
5. Where there are concerns, they must be shared in the family (unless doing so might harm a child).
6. Practitioners must be ‘culturally competent’ when using attachment-based principles.
7. Approaches to help families are more likely to succeed if we demonstrate enhanced relationship skills, specifically ‘intelligent kindness’, ‘unsentimental compassion’ and ‘non-directive curiosity’.

Working with families using attachment-based principles should complement approaches to develop stronger communities, an initiative set out in a recently published book Re-imagining child protection: Towards humane social work with families by Brid Featherstone, Sue White and Kate Morris, which I welcome. Here is how Yvonne and I set this out in our recent edited book Assessing Disorganised Attachment Behaviour in Children: An Evidence-based Model for Understanding and Supporting Families, also published a few weeks ago.

Extract from our recent book

“By focusing almost exclusively on relational dynamics between individual family members, the position we have adopted in our work on understanding attachment could be criticised for having ignored ‘external’ factors such as the myriad social injustices that exist in British society, injustices which currently are more marked as a result of many people desperately trying to survive during relatively ‘hard times’. The blatant and unfair way in which the excesses of capitalism are once more falling excessively on shoulders already broken by the weight of poverty and inequality is an outrage. But we felt that we had to restrict our focus to what we believe to be our areas of expertise: we are not sociologists or social theorists, so we must leave this aspect of child protection policy to those best able to comment on it.

Furthermore, we have an embarrassment of riches in the UK when it comes to articulating new ways of imagining child welfare, protection and the right balance between the two. We need look no further than a UK Higher Education Institute’s Joint Social Work Education Conference, entitled Positive Practice in Hard Times, at which a number of respected social work academics, in particular, professors Sue White, Brid Featherstone, Harry Ferguson, Tim Kelly and Iain Ferguson, began to articulate an agenda arguing for a re-evaluation of what we mean by ‘child protection’. The title of the White et al. paper – ‘Time to change the conversation on “child protection”: towards a new paradigm?’ – signals their intention. For them, the balance needs to shift from ‘muscular child protection/rescue discourses’ and ‘an expert screen and intervene model’ towards a ‘project that celebrates families’ strengths as well as their vulnerabilities in the context of considerable adversities and (re)locates workers as agents of hope and support’. We believe we can support their project by offering practitioners an articulation and exposition of what they need to look for to help families directly. We believe that remedial social action is needed urgently to address the attendant curses of our ‘advanced’ capitalist economy: domestic abuse, sexual exploitation, the commodification and manipulation of organised labour etc. But the causes of child abuse are complex. With the exception of chronic physical neglect which, almost by definition, is more likely to exist among poorer communities, and would be reduced by large injections of cash and/or lasting employment opportunities, other forms of child maltreatment occur in richer communities, too: sexual abuse, emotional abuse and emotional neglect are prevalent within all sectors of society. What is without question, though, is that if you are poor, you are more likely to come to the attention of child protection agencies (which would not necessarily be a bad outcome if they were able to help, but as things are as we write this Introduction, they often are not). This is not a criticism of the many dedicated child protection professionals out there; instead, it is, in part, a condemnation of the defensive, bureaucratised and proceduralised responses that have been created to protect politicians, managers, supervisors and practitioners from, at times, a predatory section of the media. So, for these reasons, we chose to concentrate on the relationship between parent and child, rather than the pernicious and unequal forces surrounding it”. (Shemmings & Shemmings, 2014, pp.15-16).

Recently, Elizabeth Meins wrote a short piece on attachment for The Conversation , which followed in the wake of comments on social media on the subject of ‘neuroscience and early intervention’. I have two observations:

1. I agree completely that ‘insecure’ attachment is relatively commonplace, at around 40%, and I always make this point in sessions with practitioners. Whilst disorganised attachment is consistently seen to be around 15% in ‘low-risk’ communities it is generally accepted that because the construct of disorganised attachment centres on the notion of ‘fear without solution’ – being frightened of or for a caregiver’ – it is now more accurate to see it, not as an attachment ‘style’, but as a precise set of behaviours that are only discernible in very specific situations and circumstances i.e. when the child’s attachment system has been activated. If disorganised attachment was a ‘style’ i.e. if it constituted a relatively permanent way of behaving, then as Patricia Crittenden said (in effect) at a recent conference in London, the child would not be able to survive for very long because s/he would become incapacitated, as the behaviours involve severely dissociative ‘inaction’. This is why disorganised attachment tends quite quickly to ‘resolve’ into one of the other three more ‘organised’ forms of attachment. (And this is why we now prefer the term disorganised attachment behaviour).

2. When I read the statement ‘parent-child interaction isn’t a particularly good predictor of attachment’ I was surprised because, given what had been written in the rest of the paragraph, I wondered if Elizabeth had meant to say ‘parent-child interaction isn’t a particularly good predictor of disorganised attachment’. If so, there are some points I would like to contribute to the discussion.
With the benefit of contemporary meta-analytic statistical techniques, we now have more information available. Such analyses have shown that, although its prevalence is slightly more elevated, disorganised attachment behaviour is still only at moderately low levels of statistical significance (a) with children on the autistic spectrum, with cerebral palsy or Down syndrome, (b) in some situations involving domestic abuse and (c) with some parents using drugs. Nevertheless, compared with maltreated children, levels of disorganised attachment behaviour were lower (Cyr, Euser, Bakermans-Kranenburg and Van IJzendoorn 2010). Temperament did not account for differences, either. As Lyons-Ruth and Jacobvitz (2008, p.699) put it: ‘the findings accrued to date indicate that attachment disorganisation emerges within a particular relationship; they do not support the notion of attachment disorganisation as an individual trait or inborn characteristic of the child’.
The situation with genetics is not really any different. At first, results suggested that a particular dopamine receptor, the DRD4 7+ allele, might affect impulse control and reward systems, and that it might partially account for higher levels of disorganised attachment behaviour (see Lakatos et al. 2002). But two subsequent studies replicated their earlier research and did not find the same connections (Bakermans-Kranenburg and Van IJzendoorn 2004; Spangler and Zimmermann 2007), the Dutch researchers demonstrating that the Hungarian team had not taken sufficient account of ‘gene-environment’ interactions. For example, a child might inherit a tendency to become overweight, but if there is very little food for them to eat, they will be underweight for their age.
Certainly some children appear to be more resilient than others, whereas others are more defenceless in the face of abusive parenting; but this resilience may be a function of who else they meet later, or who else is around to offer a degree of security, rather than emanating from a purely heritable source.
Interestingly, in their most recent meta-analysis, Cyr et al. (2010) found that disorganised attachment behaviour was related to maltreatment at a level similar to that of the combined effect of five socioeconomic status (SES) high-risk factors in a non-maltreated sample. (It is acknowledged by the authors that some of the children living in high-risk SES conditions may also have been abused, i.e. there could have been undetected or unsubstantiated cases.) This finding depends in some part on the definitions of ‘maltreatment’ given in the studies, which tend to equate it with the more ‘active’ forms of abuse (i.e. physical, sexual). But when more ‘passive’ forms of severe emotional neglect are considered, this may partly explain some of the findings. As the authors state, ‘in the absence of direct maltreatment, parental frightening behaviour might be proposed to be a key mechanism through which parents at high levels of socioeconomic risk and exposed to more traumatic experiences prompt the development of attachment disorganisation’ (Cyr et al., p.88).
Cyr et al. (2010) spell out some of the implications of their research in relation to high-risk socio-economic factors when studies have assumed that there is no maltreatment (i.e. active forms of abuse) as distinct from emotional neglect, as follows:
‘Without concrete evidence about the higher prevalence of frightening behaviour in parents from multiple-risk environments, we would like to suggest two other pathways to attachment disorganisation. First, parents’ withdrawal from interacting with the child because of overwhelming personal or socioeconomic problems and daily hassles is speculated to lead to a chronic hyper-aroused attachment system in the child. Second, domestic violence may more often occur in multiple-risk conditions … Zeanah (1996) speculates that witnessing parental violence could elicit fear in a young child about the mother’s well-being and her ability to protect herself as well as the child against the violence …’ (p.103).

In conclusion

Connections between maltreatment and disorganised attachment behaviour need to be applied carefully and cautiously. But patterns are emerging. Here are two quotes from leading attachment researchers:

‘Child maltreatment has a strong impact on attachment. It creates fear without solution for a child because the attachment figure, whom the child would approach for protection in times of stress and anxiety, is at the same time the source of fright, whether this attachment figure is the perpetrator, a potential perpetrator (in cases of sibling abuse), or failing to protect the child against the perpetrator’. (Cyr et al. 2010, p.100)

‘Disorganised behaviour is likely [to] occur when an infant is maltreated by the parent, and studies conducted by Carlson, Cicchetti and colleagues (Carlson et al. 1989) … have indicated that almost eighty percent of infants in maltreatment samples are disorganised’. (Hesse and Main 2000, p.1105).

Finally, here is David Howe, an author well known to social workers and others involved in working with children and families, writing about the connection between disorganised attachment behaviour and maltreatment:

‘In … non-clinical samples, around 14 per cent of children might be expected to be classified as disorganized … When children experience abuse, neglect, maltreatment … rates of disorganization rise to 80 or 90 per cent …’ (Howe 2013, p.153).

Wendy Smith in her book Youth Leaving Foster Care in 2011 refers to the work of Elizabeth Meins as follows: ‘(Bernier and Meins, 2008) attempt to clarify the mediating pathway between the parenting behaviour and the resulting disorganised attachment. They propose a “threshold approach” in which certain child-centred characteristics set the threshold of vulnerability or resilience to forming disorganised attachment. Insensitive or disturbing practices then breach the threshold. Social-environmental risk factors then alter the threshold level by inducing atypical parenting. For example, a parent with a traumatic history who experiences unemployment and a lack of social support has a colicky, hard-to-soothe child. The parent is frightened, angry and overwhelmed; or the parent has a substance-abuse problem and, while high or in search of drugs, ignore the needs of the child’ (Smith, 2011, p.59).

I think this is a good example of how the kind of community work advocated in Re-imagining Child Protection could dovetail perfectly with attachment-based, evidence-informed help and support by a skilled practitioner (in this case probably aimed at increasing the mindfulness – or ‘mentalising capacity’ – of the parent). It would need some skilled intervention, but that wouldn’t be enough on its own; but, equally, community development and neighbourhood action in isolation would not, I believe, be sufficient to achieve lasting change. For me, it’s both-and not either-or.

References

Bakermans-Kranenburg, M.J. & van IJzendoorn, M.H. (2004) ‘No association of the dopamine D4 receptor (DRD4) and –521 C/T promoter polymorphisms with infant attachment disorganization.’ Attachment and Human Development, 6, 211–218.

Bernier, A. & Meins, E (2008) ‘A threshold approach to understanding the origins of attachment disorganization’. Developmental Psychology, 44(4), pp.969-982.

Carlson, V., Cicchetti, D., Barnett, D. & Braunwold, K. (1989) ‘Disorganised/disoriented attachment relationships in maltreated infants.’ Developmental Psychology, 25, 525–531.

Cyr, C., Euser, E.M., Bakermans-Kranenburg, M.J & Van Ijzendoorn, M.H. (2010) ‘Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses.’ Development and Psychopathology, 22, 1, 87–108.

Featherstone, B., White, S. & Morris. K (2014) Re-imagining child protection: towards humane social work with families. Policy Press.

Hesse, E. & Main, M. (2000) ‘Disorganised infant, child and adult attachment: collapse in behavioural and attentional strategies.’ Journal of the American Psychoanalytic Association, 48 (4), 1097–1127.

Howe, D. (2013) Empathy: What It Is and Why It Matters? Basingstoke: Palgrave.

Lakatos, K. Nemoda, Z. Toth, I., Ronai, Z. et al. (2002) ‘Further evidence for the role of the dopamine D4 receptor (DRD4) gene in attachment disorganization: interaction of the exon III 48-bp repeat and the 511 C/T promotor polymorphisms.’ Molecular Psychiatry, 7, 27–31.

Lyons-Ruth, K. & Jacobvitz, D. (2008) ‘Attachment Disorganisation: Genetic Factors, Parenting Contexts, and Developmental Transformation from Infancy to Adulthood’, in J. Cassidy and P.R. Shaver (eds) Handbook of Attachment: Theory, Research and Clinical Applications, 2nd edition. New York: Guilford Press.

Shemmings, D. & Shemmings, Y. eds. (2014) Assessing Disorganised Attachment Behaviour in Children: An Evidence-based Model for Understanding and Supporting Families. London: Jessica Kingsley.

Smith, W.B. (2011) Youth Leaving Foster Care: A Developmental, Relationships-based Approach. Oxford Studies in Sociolinguistics, OUP.

Spangler, G. & Zimmermann, P. (2007) ‘Genetic Contribution to Attachment and Temperament’. Paper presented at the biennial meeting of the Society for Research in Child Development, 29 March to 1 April, Boston, MA.

Van IJzendoorn, M.H., Schuengel, C. & Bakermans-Kranenburg, M.J. (1999) ‘Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae.’ Development and Psychopathology 11, 225–249.

Zeanah, C.H. (1996) ‘Beyond insecurity: a reconceptualization of attachment disorders in infancy.’ Journal of Consulting and Clinical Psychology, 64, 42–52.

Over the past two years I have met or spoken with over 2500 social workers in various CPD events, conferences and seminars. Although the groups contained newly qualified workers, most participants were experienced professionals. I have routinely been asking them this question: ‘If you needed to find out the wishes and feelings of a child about (say) “being adopted” or “how they feel about their father/mother” etc., would you feel able to do so?’ The overwhelming majority say that, other than asking the child the question directly, they really wouldn’t have much of an idea. I also show them a clip of film from the first episode from last year’s BBC Panorama series ‘Protecting Our Children’, and then ask them ‘If you were able to work with this family for two hours a week for six months, what would you do?’ Other than drawing up a plan involving other agencies, very few feel confident or knowledgeable enough to work with the family.

However much they enjoyed their social work degree at university, which is usually spoken about with affection, respect and fondness, social workers tell me they don’t always feel it prepared them to work directly with children and families. They wonder whether their modules on psychology, sociology, social policy and social theory could have been presented differently. As one recently qualified social worker put it ‘I thoroughly enjoyed sociology and social theory … but it could have been related more directly to my practice. It was just “Sociology 101”’. However interestingly or inspiringly these subjects were taught, they wanted them focussed more on the actual job. I see this a lot in one of the modules that I have taught now for over 20 years – Lifespan Development. Unfocussed teaching of this subject consists of a series of lectures around ‘ages and stages’ which, while they may be relevant to a health visitor, teacher or psychologist, a different approach is needed in social work. Culturally-competent practitioners working with families have to understand how children and caregivers co-construct relationships inter-subjectively. A linear knowledge of, for example, Piagetian ‘staged development’ is of limited use when the worker is trying to contextualise allegations of abuse or neglect within a wider ecological perspective.

I believe that this lack of confidence about using direct work with children and families, in parallel with a perceived lack of connection between important theoretical ideas and the realities of contemporary social work practice, is in part responsible for three challenges we face at present. Firstly, it is proving harder than ever before to retain social workers after they have qualified. Compared with similar professions, HEIs do a pretty good job recruiting and keeping social work students. It’s when they start doing the work that high rates of attrition become noticeable. For example, in a study of 1738 social workers Curtis, Moriarty and Netten (2010) found that the expected ‘working life’ was 8 years for a social worker and 13 years for a social care worker, compared with 25 years for a doctor, 15 years for a nurse and 28 for a pharmacist (gender differences were weighted accordingly). But, perhaps more worryingly, the authors found that in their large sample, of those holding the relevant qualification only 25 per cent were working as social workers (Curtis et al., 2010, p.1635).

Secondly, an important consequence of this low expected working life is that more social workers need to be trained. At one level this is good news for HEIs but in reality it masks a threat because social work education becomes proportionately more expensive. A more recent report by the same authors found that, compared with health professionals, the cost of ‘qualifying a social worker’ is two to three times more expensive (Curtis et al., 2012).

The stresses of being a social worker, along with inadequate or insufficient supervision and comparably low rates of pay, all contribute to the retention and attrition problem. But, after listening to the feedback I’ve received from so many professionals, I’m becoming more and more convinced that their lack of confidence about actually helping, supporting and working with children and families is also a key determinant.

I believe that these problems will increase as a result of the third challenge, which is that a number of contemporary developments in social work practice – particularly the Munro review of child protection and the Allen report on early intervention – depend on professionals working more directly with families: a move away from ‘social work by numbers’ towards creative, mindful and reflective practice aimed at supporting families where possible.

The Frontline initiative aims to address these challenges in three distinct ways. Firstly, a different pool of potential students is explored. Other sectors do this routinely when they encounter recruitment, retention or attrition problems. One under-represented group within the social work profession is graduates from ‘top-ranked’ UK universities. Seeking social workers from among this group is seen by some academics as elitist, and based upon an assumption that such graduates will be more ‘intelligent’, or more capable of critical and analytic thinking. This is not necessarily the case, and it is recognised that good social workers need equal measures of general intelligence (i.e. what IQ tests purport to calibrate) and emotional intelligence, as well as unsentimental compassion, sensitivity, resilience, a natural sense of justice but, probably above all, ‘intelligent kindness’. The main reason why graduates from the ‘top-ranked’ universities are of interest is simply that they are an obvious group to seek to recruit because they currently do not tend to see social work as a career option.

The second way that Frontline proposes to address the challenges is by organising the teaching into a concentrated learning programme with the specific aim of lubricating the links between research, theory and practice. As one social worker put it to me recently ‘during my social work degree, I really enjoyed learning about ideas from three different sources: Carol Smart, Pierre Bourdieu and Roberto Unger. But when I watched Protecting Our Children I didn’t have much of a clue about how I could apply that knowledge’. But ‘that knowledge’ can and should be applied. There are other ways of strengthening the links. Here at Kent we are developing two: ‘interactive virtual reality simulations’ and – still in the pipeline – the use of a ‘training house’, with actors and cameras. Both developments offer practitioners a chance to try their hand at progressively more complex, demanding and challenging situations, but in a safe environment.

The third innovation within the Frontline initiative is that after a very focussed ’summer school’ students form into teams – with their peers, not with other qualified social workers – led by a dedicated and experienced consultant social worker whose role will be to help make the connections between the academic inputs and the real world of practice. Over a two year period students will receive many additional taught inputs, in particular around the acquisition of direct work skills with children and families. And by the end of the programme they will be expected to become skilled in a number of interventions; they will also receive inputs on case leadership.

The Frontline initiative will be rigorously evaluated to explore the effect on the learning experience and its transformation into confident practice with children and families. Its aim is not to replace or take over from existing university provision of social work education. Rather, it is to examine in depth key differences in syllabus content and knowledge transfer which, if successful during the Frontline pilots, should lead to adjustments and amendments to the way we do things now.

Frontline shouldn’t be feared. We should view it with an open mind, see what happens, and then apply the lessons learned within the mainstream of social work education. This open-mindedness starts by re-thinking the length of time students need to be in the ‘classroom’. The reason for the condensed period of teaching in Frontline is that classroom learning in the form of lectures and seminars only accounts for about 5% of the variation in transferability of knowledge gained at university to the task of working with families. You can get to around 10% if you add in demonstrations, and a few more percentage points if you build in reflective feedback after someone has had a chance to try things out – but only to about 25%. But if we add to this mixture coaching and mentoring, you can achieve 90-95% transferability.

This is what can be different about Frontline. It draws the lecture hall into the real world of practice. This is important because social workers say they lack confidence in direct work, critical analysis and how to apply research-based and theoretically-informed insights learned at university to their work with families. It’s unhelpful to think of the period of teaching as ‘it’s only five weeks’ – that’s just the pure ‘academic’ component which, in and of itself, rarely leads to transformative social work. That happens as a result of mentored and reflective practice with inspirational teachers in the workplace who help make the links to classroom-based theory and research.