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.