Special Report: Attachment and Neglect - Research Evidence


Research in Practice - The research section for this special report is based on a selection of academic studies that have been explored and summarised by Research in Practice (www.rip.org.uk), part of the Dartington Hall Trust.

STUDY 1

  • Applications of the dynamic maturational model of attachment with children involved in care proceedings
  • Daniel T Wilcox and Clark Baim, Child Abuse Review (2015)

Attachment theory focuses on the importance of deep emotional bonds for social, emotional and cognitive development, according to one of its pioneers, John Bowlby.

Dr Patricia Crittenden, a developmental psychopathologist, in 2010 observed that as children mature, attachment strategies become more complex as they develop the ability to process information in more sophisticated ways.

Her concept of the Dynamic-Maturational Model of Attachment and Adaptation (DMM) thus emphasises the dynamic interaction between maturing human beings (for example, growing children) and the contexts in which they live and keep themselves safe.

This paper focuses on the DMM as a framework for understanding the root causes of the difficulties of children in care and family proceedings.

The authors outline the model before providing two anonymised case examples, one of which is summarised here. The full article is intended to act as a “primer” for practitioners undertaking assessments and developing interventions. Three different patterns of attachment are described.

A strategy

Through predicable but poorly attuned care, a baby learns that expressing emotion makes things worse (when she cries she is routinely ignored or abused).

However, this child’s emotions still simmer under the surface, and may sometimes present as aggression, distress or comfort seeking. In toddlerhood, she may develop a caretaking role to get close to a psychologically unavailable parent or develop a compulsively compliant strategy to appease an abusive or demanding parent.

From puberty, the A strategy may also incorporate promiscuity (to meet needs for comfort without closeness) or self-reliance (to avoid being hurt).

B strategy

Through receiving predictable care (when she cries out someone comforts her) that is accurately attuned to her needs, a baby learns that both thoughts and feelings have self-protective value. This is the optimum environment in which to develop.

C strategy

Through receiving care that is unpredictable and variably attuned, a baby learns that exaggerating her emotions gets results.

Moreover, the child learns that to get her needs met she must not only get her caregiver’s attention but keep it. This confuses her carer, who is unaware that their inconsistency makes the child’s behaviour worse.

Typically, in childhood, aggression will be juxtaposed with displays of helplessness to disarm potential retaliation. From puberty onwards, the child may develop aggressive strategies that are focused on punishing the other person, and/or seek to be rescued.

Case example

The need to find the right strategy is illustrated in Tammy’s case. Tammy is an eight-year-old girl whose mother, Ms W, has a history of depression, physical and sexual abuse and violent relationships. Ms W’s supervision of Tammy is considered inadequate and she has previously failed to report the sexual abuse of her daughter by a cousin and her partner. Tammy was removed from her care due to neglect and sexual abuse.

Clinical presentation:

  • Exceptionally needy with significant attention-seeking behaviours, for example, imitating infant behaviours during contact
  • Disruptiveness including hitting and lying
  • Behaving spitefully, for example intentionally causing distress to other foster children about contact with their parents
  • Poor self-care
  • Poor capacity for sharing.

Case formulation:

Tammy evidenced a Type C attachment pattern and her clinical presentation suggested significant adjustment difficulties that were likely the result of wide-ranging abuse and neglect: “Regularly changing her response-set in a desperate attempt to keep her mother involved with her to address a kaleidoscope of changing problems, the resolution of which was not so important as the process of maintaining a dialogue and sense of connectedness.”

Ms W was unaware that it was her inconsistency that worsened Tammy’s behaviour.

The assessing psychologist concluded that Tammy could not be returned to her mother’s care, a view upheld by the court.

A long-term secure fostering arrangement, where she was the only child, was advised so that Tammy’s confidence could build in an environment where she did not need to compete for attention. A referral to child and adolescent mental health services for Tammy to receive therapeutic support was also advised.

Implications for practice

While assessing and treating attachment issues can be complex, particularly where a child has experienced extended trauma, the authors suggest that distinguishing between the A and C strategies will help practitioners to develop more focused interventions.

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STUDY 2

  • Applying attachment theory to effective practice with hard-to-reach youth: the AMBIT approach
  • Dickon Bevington, Peter Fuggle and Peter Fonagy, Attachment and Human Development (2015)

Adolescent Mentalization-Based Integrative Treatment (AMBIT) is a team-based approach to working with young people who may have multiple issues, yet do not seek support or accept that which is offered.

AMBIT is being developed in collaboration with more than 80 UK local authority and charitable sector teams and the NHS.

The article reviews the core features of AMBIT, exploring applications of attachment theory to create the conditions for increased security in young people’s attachment to a worker.

Mentalisation

Mentalising is the function of coming to understand and communicate about behaviour (one’s own or that of others) in terms of mental state – beliefs, fears, hopes, wishes and intentions. It is key to social communication and the gathering of social information.

Evidence supports the notion that mentalising is not a biologically inherited function, but one that develops in the context of attachment relationships as an infant experiences their own mental states being accurately understood and communicated by a trusted other, via imitative facial and verbal gestures.

To mentalise, a non-expert stance must be adopted, accepting the limits of current understanding about the mind, inquisitiveness to develop such understanding, and gentle humour focused upon the common human experience of misunderstanding each other.

Working in teams

The AMBIT stance is defined within a visual wheel by eight paired markers that create conditions for secure expectations in key relationships between worker and client and between colleagues.

These include: managing risk; scaffolding existing relationships; respect for local practice and expertise; respect for evidence; individual keyworker relationship.

These are linked to four practice elements applied to clients, the team and the wider service networks. All these elements are integrated around an effort to protect and promote mentalising, which is seen as the “axle” carrying forward therapeutic change.

Working with clients

The AMBIT stance balances scaffolding existing (attachment) relationships with an attention to maintaining good risk management and to avoid the “disintegration” that occurs when different parts of a system fail to mentalise each other accurately, overwhelming workers and young person respectively.

AMBIT is presented as a learning framework to be adapted constantly to evidence and experience.

A case study is provided throughout the article, showing how mentalisation and the AMBIT model can be used to build trust within an attached relationship between a professional and a young person.

By showing an interest in understanding the mind of a young person, he or she is more likely to be receptive to the social messages/learning that the worker may wish to impart.

The authors point out that while AMBIT needs further formal evaluation in the coming years, its emphasis on flexibility presents additional challenges to this.

Web-based platform

Using open-source wiki technology AMBIT offers a web-based platform of core manualised content, which is shared to multiple local versions where teams are supported to record and share their own local learning and attuned local practices and strategies – offering a supportive social network.

STUDY 3

  • Linking lack of care in childhood to anxiety disorders in emerging adulthood: the role of attachment styles
  • Adriano Schimmenti and Antonia Bifulco, Child and Adolescent Mental Health (2015)

This study looks at the effects of childhood experiences of neglect and abuse and insecure attachment styles on the development of adult anxiety disorders in a high risk sample of adolescents.

Understanding developmental pathways from childhood emotional neglect to adult anxiety disorders can help practitioners to develop preventative measures.

In 1973, John Bowlby suggested that the roots of adult anxiety are found in childhood and this idea has been developed to assist understanding of the role of neglect in the development of anxiety disorders.

Parental emotional neglect comes in many forms, such as rejection, withholding love or belittling. The three broadly accepted patterns of attachment are secure, anxious-ambivalent, and avoidant. Cristina Colonnesi et al found anxious-ambivalent attachment was most closely associated with anxiety disorders.

This study consisted of 160 young people aged between 16 and 30, with whom interviews were conducted in the home. They were selected based on their mother’s profile as:

  • Registered with GPs in Islington
  • At high risk of depression
  • Negative current relationships (with partner, child, or no close support)
  • Negative childhood experience before age 17.

Negative childhood experiences

Use of the standardised Attachment Style Interview found 47 per cent of the young people showed insecure, 28 per cent anxious and 19 per cent avoidant attachment.

Of the sample, 18 per cent experienced anxiety disorders, more than two-thirds of whom were female. Disorders included generalised anxiety disorders, social phobias, and panic.

Further analysis was carried out to understand whether childhood experiences of poor care, abuse or insecure attachment were predictive of anxiety disorder, using the Childhood Experience of Care and Abuse scales.

These scales did predict anxiety disorder, with parental antipathy shown as a key indicator, but other scales of abuse or poor care did not predict anxiety disorder.

Parental antipathy a key indicator

The results demonstrate that parental antipathy is the strongest indicator of anxiety disorder in this sample of young people.

This is consistent with the concept that parental rejection, coldness, neglect of needs and unavailability may be at the root of understanding the development of emotional disorders.

The analysis suggests adolescent onset of anxiety disorders may be linked to anxious-ambivalent attachment styles and the accompanying factors of a fear of rejection or separation.

This is consistent with Bartholomew and Horowitz’s description of anxious attachment styles as having a negative self-image, seeing themselves as inadequate and not worthy of love, and consequently needy. The combination of poor self-esteem, low self-efficacy and ambivalence regarding relationships can lead to internalising symptoms of anxiety and depression.

Implications for practice

While the findings of this study are important, certain limitations need to be acknowledged. Among these are:

  • The sample was selected from high-risk mothers, so findings are not generalisable to broader populations
  • Key experiences of childhood were sought retrospectively, which may contribute to bias
  • Only anxiety disorders were considered, with no analysis of other disorders that may have been present and their impact
  • Nevertheless, the findings still suggest emotional neglect in the form of cold, critical parenting is a strong indicator of anxiety disorder. Such parenting contributes to adolescents developing internal working models preoccupied with relationships, ambivalence in trusting others, and low self-esteem, which puts them at greater risk of anxiety disorder. On this basis, professionals working with anxious children and adolescents may wish to give thought to how to work through these anxious-ambivalent attitudes in order to build self-esteem and develop the therapeutic alliance crucial to assisting more in-depth consideration of these issues in order to reduce anxiety.

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STUDY 4

  • Review: Attachment and attachment-related outcomes in preschool children – a review of recent evidence
  • Jane Barlow, Anita Schrader-MacMillan, Nick Axford, Zoe Wrigley, Shreya Sonthalia, Tom Wilkinson, Michaela Rawsthorn, Alex Toft and Jane Coad, Child and Adolescent Mental Health (2015 )

Secure attachment is linked to optimal outcomes in all areas of childhood. De Woolff and Van Ijzendoorn have found that about 60-70 per cent of children are securely attached and between 15-19 per cent of children show disorganised attachment. In disadvantaged populations this has been seen to rise to 30-40 per cent and in maltreated infants to 70-80 per cent.

The impact of early parenting experience is well documented and this has been developed to increase understanding of the quality of parent/child attunement and mind-mindedness.

This paper considers the effectiveness of interventions intended to improve attachment and attachment-related outcomes. Six systematic reviews and 11 randomised control trials met the criteria for inclusion in the review.

Attachment

Six papers looked at whether interventions changed infant attachment. Parent infant/toddler psychotherapy (PIP), where a therapeutic alliance is formed with parent and child to identify parental behaviour linked to their internal working model, found children were more likely to be securely attached following PIP, but no significant difference when compared with other models such as counselling or video feedback.

This leads the authors to conclude that, while PIP is promising, more work is needed to understand its impact on factors such as mental health and reflective functioning.

Bernard et al evaluated the Attachment and Bio-Behavioural Catch-Up (ABC) programme. This manualised intervention of 10 one-hour sessions provides parents with “in the moment” video feedback, highlighting strengths and areas for development.

Results were positive with 34 per cent of the ABC children showing disorganised attachment compared with 57 per cent in the control group.

Sadler et al evaluated Minding the Baby (MTB), a mentalisation-based home-visiting programme designed to improve the reflective function of first-time mothers aged 14-25 experiencing a range of challenges during the perinatal period including child protection issues, depression and violent relationships.

A nurse and social worker alternate weekly visits until the child is two, providing guidance, intervention and support, and modelling parenting skills.

Secure attachment was found in 64 per cent of the MTB group compared with 48 per cent of the control group. The MTB group showed zero open child protection cases as opposed to five per cent in the control group.

No significant differences were found in terms of maternal reflective functioning, depression or psychological distress, but improved communication was apparent for teenage mothers.

Attachment-related outcomes

Five systematic reviews and five randomised controlled trials (RCTs) evaluated attachment-related outcomes. Bennett’s systematic review of infant massage found this had no significant impact with low-risk populations, so future work should focus on demographically and socially deprived groups.

One review and three RCTs looked at video feedback programmes.

The review found the effect on child behaviour to be “small” or “average”, with greater impact on parental interaction skills, which consequently assist child development.

The RCTs included high-risk parents, and one culturally adapted programme. Results showed significant improvement in areas such as emotional availability and family environment.

The impact of home-visiting programmes on maternal behaviours was moderately successful. The Mothers and Toddlers Programme (mentalisation) showed sustained improvements in reflective functioning, but initial improvements in depression were not sustained.

An RCT evaluating parent-child psychotherapy found improvements in child post-traumatic stress disorder that was five per cent for those who participated in the intervention compared with 53 per cent in the control group.

Implications for practice

  • Results show parent-infant psychotherapy, video feedback and mentalisation-based programmes are promising with high risk groups
  • The theories of change underpinning these approaches are diverse
  • The regularity and duration of interventions is also diverse and there is little evidence to say what regularity or duration is most effective
  • While non-specialist practitioners can deliver some interventions, the prevalence of disorganised attachment and its association with later problems suggests specialist child and adolescent mental health services practitioners may be needed in some cases.

FURTHER READING

Child neglect is everyone’s business, Buchanan et al., LARC 6, (2015)

We should have been helped from day one, Easton et al., LARC 5, (2013)

In the child’s time: professional responses to neglect, Ofsted, (2014)

New Orleans Intervention Model: reducing the risk of abuse and neglect, (NSPCC)

Attachment (Updated) Briefing Research in Practice, (2016)

NICE guideline - Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care, Research in Practice webinar with David Shemmings, (2016)

Emotional abuse and neglect: identifying and responding in practice with families, Research in Practice briefing, Anita Schrader-McMillan, Jane Barlow and Danya Glaser, (2014)

Adolescent mental health, Research in Practice briefing, Dr Dickon Bevington, (2015)

Promoting resilience in children, young people and families, Research in Practice briefing, Newman T, (2011)

Child Development Briefing, Research in Practice, Donnellan H, (2010)

Building reflective practice: Using mentalisation theory in effective direct work Learning Event, Research in Practice, (2016)

Analysis and critical thinking in assessment 2nd Edition: Handbook, Research in Practice, Liz Brown and Sarah Moore, (2014)

Research in Practice, research and policy updates, numbers:

  • 166 on adolescent mental health, January 2015
  • 170 on neglect, May 2015
  • 151 on attachment, September 2013
  • 148 on neglect, May 2013

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