Audio transcript: Children's attachment needs in the context of out-of-home care

Return to CFCA webinar - 16 November 2016

Audio transcript (edited)

Robinson

Good afternoon everyone, and welcome to today's webinar, "Children's attachment needs in the context of out-of-home care".  My name is Elly Robinson and I'm Executive Manager of Practice, Evidence and Engagement here at the Australian Institute of Family Studies.   Today we will hear about attachment theory, what we know from the research and how this can inform placement decision making in the context of out-of-home care.  The webinar builds on a practice paper that was published this week.  If you haven't already seen the paper, you will receive a copy at the end of the presentation today.  Before I introduce our speaker, I would like to acknowledge the traditional custodians of the land on which we meet.  In Melbourne, the traditional custodians are the Wurundjeri people of the Kulin nation.  I pay my respects to elders past and present, and to the elders from other communities who may be participating today.  

I would also to like to alert you to some brief housekeeping details before we start.  One of the core functions of the CFCA information exchange is to share knowledge, so I'd like to invite everyone to submit questions via the chat box at any time during the webinar, and we'll respond to those questions at the end of the presentation.  We'd also like you to continue the conversation we begin here today.  To facilitate this we've set up a forum on our website where you can discuss the ideas and issues raised, and submit additional questions for our presenters.  We will send you a link to the forum at the conclusion of today's presentation.  Please remember that this webinar is being recorded and the audio, transcript and presentation slides will be made available on our website and YouTube channel in due course.  

It's now my pleasure to introduce today's presenter. Dr Sara McLean is a registered psychologist and Research Fellow at the Australian Centre for Child Protection.  She has worked in the area of child and adolescent mental health since 1997, and has a particular interest in developing effective supports for children in care.  Sara has expertise regarding the psychological issues associated with foetal alcohol spectrum disorder and the mental health and behavioural needs of children living in foster and residential care.  Sara was recently awarded the inaugural ACU Linacre Fellowship at Oxford University, in recognition of her work supporting children in care.   Please join me in giving our presenter a very warm virtual welcome.  Over to you Sara. 

McLean

Thank you, Elly, and thank you everyone for joining me today. I appreciate you taking the time out of your busy schedules to join me.  Today I'd like to talk about – broadly – about the topic of attachment theory, and what it means for the support that we offer children in care.  In particular, I wanted to focus on something a little bit different than what I spoke about in the practice guide, and that is, I want to talk a little bit about the theory of attachment, some of the historical research that has been done in that space, and really with a view to highlighting some of the reasons why perhaps there has been an over-emphasis on the connection between challenging behaviour and attachment for children in out-of-home care.  So I'd really like to focus on that.  I'd also like to speak to some of the other approaches to supporting children in out-of-home care that might offer us more evidence base than attachment theory, and I'd also like to highlight some of the ways that attachment theory is used in out-of-home care – particularly ways that it seems to be misunderstood and what the implications might be for young people.  

So very briefly about myself.  As Elly mentioned, I'm a registered psychologist.  My background has been in child and adolescent mental health and, for most of my work as a psychologist in child and adolescent mental health, I've worked as a senior clinical psychologist in two therapeutic day programs for children with serious and significant mental health issues, and particularly with behaviour that is of a level of concern and a level of significance that meant that children were not able to access normal community facilities, or to access schooling and education.  And what I realised in that service, that around 80 per cent of those children that we were offering support to, actually were living in foster, residential care or had a history of foster care.  So I became interested in how to deliver more effective supports to this group of children.  

Since starting at the Centre, really a lot of my work has been focused on critical analysis and reflection about the kind of services that we offer children, about the theories that underpin those services and some of the myths and misperceptions associated with the needs of children in out-of-home care.  And most recently I've been looking, in particular, about some of the contributors to behaviour disorders; to the development of behaviour issues in children in out-of-home care and most recently have been focusing on prenatal influences, including foetal alcohol spectrum disorder and the significant impact of placement stability on children's behaviour and development.  

So my view is that attachment continues to be an incredibly influential theory in out-of-home care practice and policy.  It has been for a long time.  I've recently read one study in relation to children who were released for adoption in Scottish out-of-home care system; and in that analysis of reports to the court, 100 per cent of those focussed on the attachment needs of the child.  It's incredibly influential theory in out-of-home care practice.  And more recently, I conducted some work in which I was asking people about their understanding of the challenging behaviour of children in out-of-home care.  And in that large scale study, attachment explanations were most often put forward for children's challenging behaviours.  So behaviours were explained in terms of attachment issues, attachment disorder, and so on.  

It's really understandable that attachment takes such a focus in our work in out-of-home care.  It makes intuitive sense to us that we would like to think about children's attachment problems, because we know their placement in out-of-home care does involve a disruption of a significant – at least one significant – relationship.  But in reality, attachment theory has very little to say about the needs of children in out-of-home care.  So today I'm going to talk a little bit about some of the reasons why there is this over-emphasis on the link between behaviour – challenging behaviour – and attachment and critically evaluating some of the evidence around that.  

I'd like to put that in context of some of the other evidence based programs and interventions that we could use to support children.  And I'd also like to spend a little bit of time really highlighting some of the ways that attachment theory is used and talked about, in terms of the needs of children in out-of-home care, that really seem very inconsistent with actually what the theory says.  And hopefully we'll have some time at the end to really reflect on what the impact might be for children in terms of our decision making about their placement needs and their behavioural needs.  

So my argument is that attachment is the dominant theory in relation to challenging behaviour in child protection practice.  I think that's true in Australia and I think that's probably true internationally as well.  Certainly in my work I've found it's the most frequently given explanation for children's needs and particularly for behaviour that challenges place and stability.  We as clinicians, as foster parents, as people, are very motivated to heal and care for children.  There really is a great attraction to the idea that we can heal a child's broken attachment through providing love and care.  This is a much better alternative than the reality that we may actually have – that children may have experienced significant harm in their early life and that we may have to put in sustained and targeted supports to help them recover.  

Some of the attraction of attachment theory has come from early psychological experiments, and many of you will be familiar with Harry Harlow's experiments on rhesus monkeys, where he raised infant monkeys in a cage with pretend mothers made out of wire, one of which was a wire mother that delivered food, and one of which was a wire mother that was covered in soft cloth.  And he was very surprised to find that baby monkeys tended to cling to the soft cloth covered wire mother rather than the food.  

So they preferred – his interpretation was – they preferred love over food.  And this was a very influential experiment in attachment theory, and has really driven this belief that attachment is a formative critical experience of child development.  At heart though, attachment theory is a developmental theory and it's not a clinical one; although we frequently hear attachment theory talked about in terms of a clinical or a therapeutic intervention. In reality attachment theory doesn't tell us much about what to do to support children's attachment needs.  

Attachment theory is also unique in that it has evolved out of a whole different range of evidence basis.  It has evolved as developmental theory, but it's been influenced by evolutionary work, psychodynamic work, behavioural work, and psychiatric diagnostic work.  And in some ways this unique history has contributed to the confusion that we have around what attachment is and what's a normal attachment and what's abnormal.  And, of course, it contributes to confusion about what's the relationship between attachment and behaviour, behaviour problems. 

So attachment is a theory that's really most salient – most relevant – to the first few years of a child's life.  It's a developmental theory that basically says that the early attachment relationship offers a template of later subsequent relationships and psychosocial development.  It places great emphasis on the innate biological drive on the part of the infant to form an attachment bond with a responsive care giver.  A central aspect of this is the infant's ability to signal when they are distressed and to elicit comfort on the part of the care giver.  So an intricate part of the attachment bond is the signalling, and the way that the child learns to signal distress and to elicit comfort from their care giver.  

But it's important to remember this is really a one way bond.  A child forms an attachment with a parent, but a parent doesn't form an attachment with a child, and we often hear that confused.  So a child forms an attachment with a parent because a child learns to elicit comfort from a parent at times of distress.  But ideally, a parent doesn't do that with a child.  So an attachment is a one way bond.  And ultimately the result of an attachment experience is the child develops an internal working model, a representation of their care giver, but also what kind of behaviours they need to engage in in order to elicit comfort from that care giver and to keep that care giver close.  So it offers a template or a schema or a kind of a mould for later social behavioural development.  

Now I'm aware that we have a very mixed audience today, so I would like to go back through some of the original theory of attachment, because I think this is important in understanding how we've come to emphasise, or perhaps over-emphasise, the link between attachment and behaviour.

So our contemporary understanding of attachment theory has come from two largely independent bodies of research into the role of early attachment experiences and its role in child development.  But both those bodies of literature have looked at behaviour in different ways.  So these different approaches and different populations, these different study approaches, has really contributed to the confusion that exists in the literature about the relationship between attachment and behaviour.  There's a whole set of behavioural paradigms, experimental paradigms, devised by psychologist that focus around the stranger situation.  And this is a highly structured assessment tool in which you can categorise children's attachment according to their behaviour.  

There's also a set of research that has come about through the work of psychiatrists who have catalogued – or categorised – some of the behaviours of children who have been raised in orphanages, in environments of prolonged neglect, and in the absence of a specific care giver.  So neither of these bodies of evidence really gives us much information that is directly applicable to fostered children, because those bodies of evidence were developed in very different populations.  But these bodies of work have been very influential in embedding this idea that attachment disturbance is synonymous with behavioural disturbance.  

So the first point I'd like to make is that most attachment is normal – within normal limits.  Our understanding of attachments and the types of attachments that children can form, has come about through very structured experimental procedures where children were placed in a room with their care giver, their care giver left the room – so they were subject to a separation – and then their care giver came back in the room, so they had a reunification after a defined period of time.  So it was a very structured setting.  And what they found is that children, in this kind of structured setting, behaved in very predictable ways.  Importantly, the behaviour that the experimenters observed was used to infer something about the child's attachment status.  And in particular, about the internal working model of attachment that they had developed.

So as I said, most children responded in very predictable ways.  Some children were classified, based on their behaviour, as securely attached.  So these children freely expressed emotion and went to the care giver when the care giver responded.  And that was seen to reflect an internal working model of being loved, having a predictable care giver, and it being safe to express emotion.  But some children were classified as insecurely attached.  So those that were avoidant, minimise their emotional expression once a care giver returned, and that was seen as reflecting an internal working model that they needed to suppress their emotions in order to keep the care giver by their side.  Similarly, other children were insecurely attached and they had an ambivalent behavioural expression.  So these children learned to overreact or to be really expressive once the care giver returned.

And the theory was, that these children had developed an internal working model of attachment in which they had to be very expressive in order to attract the care giver's attention; and theoretically, because the care giver was inconsistent in their response to their emotions.  So that's all a very long winded way of saying that children, in this highly structured experimental situation, behaved in – had sets of behaviours that were fairly predictable.  But all of these ways of behaving are entirely normal and we sometimes forget that when we talk about children's needs in out-of-home care we quite often hear about children being evidently attached, insecurely attached, or ambivalently attached. I just really want to emphasise the point, this is all within the realms of normal child development. So children outside of out-of-home care also display these behaviours in relation to this strange situation protocol.  But they're organised ways of responding.  So the theory is that these children all had enough of consistent response from their care giver that they were able to form relatively organised, consistent ways of viewing their care giver, consistent ways that they knew they had to behave to elicit comfort from the care giver.  As I said, these are all entirely normal behaviours.  Despite this we hear about these behaviours being signs of attachment disorder.

However, there was also a group of children who could not be classified.  That is, they didn't have a consistent way of responding when their care giver returned, and these children were classified as having a disorganised attachment.  That is, they hadn't had a consistent enough experience of care giving to have developed this internal, consistent internal working model.  These children were thought, said to have a disorder – disorganised attachment style – and thought to have no consistent way of representing attachment.

These young people with a disorganised attachment have been shown to be an increased risk of dissociative symptoms in adolescence, or mental health issues later in life, but we're really unclear still about how disorganised attachment during the early years – if you measured disorganised attachment in this highly structured situation – how that actually relates, or it turns into psychopathology, later on in life.  We certainly also know that disorganised attachment is linked with certain care giving characteristics, such as having unresolved trauma, not being emotionally available, being frightening or behaving in frightening ways to the child.  And that – I go into that in more detail in the practice paper.

So although behavioural observations and observations about behaviour were key in discovering and uncovering these attachment styles, most of these behaviours were within the normal – realm of normal – child development, and were only demonstrated in this highly structured situation.  Despite this, the belief still persists that we can observe, we can determine children's attachment from observing their behaviour.  And I really just wanted to emphasise that you cannot make that distinction outside of this highly structured and well validated assessment situation called the strange situation.  And also, the other point I wanted to make about disorganised attachment, is that it's considered a very temporary immobilisation involving bizarre behaviours, but it's a temporary response to attachment insecurity in the presence of a care giver, so it can't be assessed outside the presence of the care giver.

So the second body of work that has been influential in linking attachment to challenging behaviour has been the work on reactive attachment disorder.  And this body of work came from studies of orphans who were raised in institutions under conditions of prolonged neglect, and in the absence of a specific care giver.  And unlike these other attachment classifications, these diagnoses were made when these children met strangers, in response to their behaviour to strangers, rather than in the care-giving context.  And there were two types; so psychiatrists observed these children and categorised children according to two strong behavioural clusters.  The first was, the disinhibited reactive attachment disorder, which was marked by indiscriminate social behaviour, not recognising strangers from familiar people – not making that distinction – disinhibited behaviour.

And the second form was an extremely inhibited social behaviour.  So not being receptive, responsive to social interaction, being extremely reserved and hypervigilant.  So two very distinct but very marked behavioural presentations that arose and that were documented in the context of prolonged neglect and prolonged absence of a specific care giver.

We know that attachment – reactive attachment disorders – are extremely rare.  We also now know, with the advent of the DSM-5, that this first type of reactive attachment disorder, the one with the most marked behavioural characteristics, is actually now not considered to be attachment disorder at all, and so the name has now been changed to disorder of social engagement to reflect the fact that it's actually more about social violations – a disorder of socialisation rather than an attachment disorder.  So children who have this diagnosis and then who are adopted, do change their attachment classification.  So it's independent of attachment is what I'm trying to say.  So the attachment experience does not account for the behaviour; and yet the belief persists that disinhibited behaviour and poor social boundaries is an attachment issue.

Okay, so very briefly to put this all in perspective.  We acknowledge that attachment is a key developmental influence for kids.  It shapes – it could be seen more like an influence that shapes children's personalities in all of these areas.  So it shapes their capacity for emotional regulation, it shapes what they believe about the behaviours they need to engage in in order to to be loved by a care giver or to keep a care giver close, it shapes how they view themselves and others and their worldviews about safety in the world, and the safety of themselves and safety of others, and it also influences or shapes whether they are rewarded by social consequences or they have a pro-social orientation.  So it kind of shapes personality but it doesn't, there's no evidence that it trumps other factors such as placement stability, high quality parenting, good social connections, and other opportunities, and yet we persist in that belief particularly in relation to children in care.  

Okay, so neither of these attachment difficulties – disorganised attachment or reactive attachment disorder – really contributes much to our knowledge about what to do in out-of-home care practice.  We know that disorganised attachment is more common in maltreatment, and it’s linked to later pathology, but it's specific to the care-giving relationship.  It can't be demonstrated outside of that and it's normally a temporary response to activation of attachment need.  We can't actually document it outside of that strange situation.  So we kind of can think of it more as a state of being rather than a trait; so something that's temporary, not enduring.  And we know that it's linked to later psychopathology but we really don't know exactly what the pathway is.  We just don't have enough information about that.  And similarly with reactive attachment disorder, it also doesn't offer us much in terms of understanding behaviour of children in out-of-home care.  

The one form of the disorder that was associated with strong behavioural presentation – disinhibited presentation – has now been accepted not to be an attachment disorder as such.  And there are other potential explanations for this kind of disinhibited behaviour that we sometimes see in children in out-of-home care.  And one that springs to mind for me is, of course, the presentation of children with foetal alcohol spectrum disorder, who can present in this very disinhibited way.  Okay, so all of that is a real long winded way of saying that there's good reasons why we have historically over-emphasised the link between attachment and behaviour, but that relationship is not really supported by the literature.

The second point I wanted to make was whether we could have more impact on children's lives by focussing on placements, focusing on more evidence based approaches to supporting children with challenging behaviour, and therefore supporting placement stability.  So this table gives you an overview of the kind of disorders – for want of a better word – the kind of difficulties that kids can have in out-of-home care, that are common to out-of-home care, that are clearly associated with neuropsychological difficulties and that have well documented treatment approaches.

So you'll see here, for example, that conduct disorder conservatively and reliably is estimated to occur in around 60 per cent of the out-of-home care population.  Ten times more common than regular population.  Foetal alcohol spectrum disorder we think something in the vicinity of 17 per cent of children in out-of-home care, and so on.  You can see learning difficulty 37 per cent, anxiety 11 per cent.  In contrast, reactive attachment disorder is a very small proportion of children in out-of-home care, and while disorganised attachment is very common in out-of-home care, as assessed in this very prescribed situation – a strange situation – it is also commonly found – 10 to 15 per cent of the population – who are not in out-of-home care, exhibit disorganised attachment in that assessment situation.

And you'll see in the right hand column, what I'm trying to emphasise there is there are well documented interventions for any of these other disorders that are also associated with challenging behaviour.  What we are lacking is well documented interventions for disorganised attachment.  Okay, so the third issue that I really want to highlight is to talk about some of the misunderstandings and misapplication of attachment theory that I have come across, together with some of the limitations, or the implications, of these misunderstandings that I really want to highlight.

The first really relates to the use of attachment theory in general, but to the idea of attachment disorders and the related literature.  My view is that it doesn't – the literature surrounding attachment disorders neither, the literature related to disorganised attachment or reactive attachment disorder, really offers us any useful information in terms of developing supports for children in out-of-home care.  I really want to emphasise that attachment theory is not a clinical theory, it does not offer clinical guidance generally speaking, but of course it has been used in that way.

I'd really like to encourage us to look for factors outside of attachment to explain children's behaviour, and really look at simpler explanations that offer more in terms of the direction for our intervention and our supports.  So we know from reviews of brain development in early life in the context of adversity, that there are well defined – well documented – issues such as memory difficulties, executive function difficulties.  Things like high levels of anxiety.  We have a very good record of the kind of issues that young people in out-of-home care can experience.

We might do better for young people to focus on those issues where there are well supported interventions, rather than focusing on trying to attain a secure attachment.  And one of the issues for me is that if we were really focusing on attachment all the time, what does it mean then if the placement isn't stable.  What are the implications?  What are we saying about children and what are we saying about carers?  If the placement becomes unstable, are we saying that it's a failure of the child to attach or is it a failure of the foster carer to develop, provide nurturing care?  Could there be other explanations that offer more in terms of a way forward?

The other point I'd like to make is that attachment's been widely criticised because it lacks a consensus definition around terminology, and this opens the door for drift or a broadening of concepts to include virtually anything.  So some of the concepts that I've heard discussed in the context of children's needs include their attachment bond, their attachment relationship, their attachment behaviours, attachment and trauma, and the most recent, attachment trauma.  It's a real issue for me that we really need to become a little bit more clear about what we're talking about, when we're talking about children's attachment.  If we have a group of professionals – and typically there's multiple people involved in making decisions about young people's lives – we don't want to be – is it helpful to be using a concept that is so open to interpretation, or are there other ways we can talk about children's needs?

Much of the discussion about placement needs of children in care focuses on the need to form a primary attachment.  What I'd like to highlight is that children form multiple attachments at a very young age and, in some ways, us pursuing a primary attachment to a foster care, we need to be careful that it's not done at the expense of children's other significant relationships.  It doesn't mean that a primary carer isn't important.  But a primary carer is different from the idea that a child needs a primary attachment figure after a certain age.  In my view, the seeking of primary attachment figure can be misleading, and the decisions about where a child lives and how often they should have contact, are much better based on issues of safety, the child's developmental need, how unsettling family contact is, the child's wishes, rather than the rationale of developing a primary attachment.

The other difficulty that we're faced with in out-of-home care is that a foster carer – a placement in foster care setting, foster care home – is not going to be, in most cases, the child's first attachment, yet we do treat it as though it is.  We don't know very much, there isn't very much literature about whether this kind of placement and this kind of attachment bond that a child forms with their foster parent is or is as protective – in terms of mental health outcomes – as their original attachment.  We don't know how that interacts with other things, including placement stability, child's developmental age, and so on.

But there has been a little bit of preliminary work which shows that children are unlikely, actually, to form any secure attachment subsequent to their original attachment if their original attachment wasn't secure.  So it may be that they end up forming the same similar kind of attachment to their foster parent that they had with their mother or their parent.  But research in this area is really in its infancy.  So are we actually being realistic if we are pursuing the holy grail of the secure attachment?  There is also no reason to believe that there are any cultural differences in attachment in terms of the distribution of attachment organisation.  So what I mean is that, if you put the children in any country where it's being measured through the strange situation protocol – which is the only well established assessment tool for young children – then the proportion of attachment organisations comes out very similar.

But what is different is cultural definitions of what good parenting is and what responsive parenting is, and there are cultural differences in what we value in terms of children's development.  So we tend to value self-efficacy, exploration, whereas other cultures might value independence, interdependence, dependency and so on.  So there are cultural conditions around how we assess attachment and parenting.  Another significant point is that we really don't know much about attachment beyond the first few years where there are rigorous assessment protocols and it's been well researched.  We don't know how early attachment experiences interact with later peer social relationships, the relative importance of peer relationships as children enter school age, or wider family relationships.  And how does their attachment experience interact with their developing, you know, awareness of the world and so on.  We don't know much about that.

As I mentioned earlier, even attachment theorists and attachment development theorists, do not themselves state that attachment determines later development.  Rather they view it as a template or a schema or a kind of a foundation of later development.  And when we look at attachment interventions, when we go to the literature and look at the attachment interventions, when a large meta-analysis, when we look at a meta-analytic work that's been done on effective attachment interventions, we actually find that effective attachment interventions are very focused, very discrete in their time limit, they're targeted to younger children, and they are very behavioural in the sense of their focusing on parenting sensitivity.  So if we wanted to develop attachment interventions, we need to ensure all of those criteria are met.  And I would argue that often those things aren't, and that generally our support for foster parents tends to be quite broad.  

Okay, so just to finish now, I just wanted to finish on a couple of points.  Really just to emphasise that there's really not a great deal of support for the direct link between behaviour disorder – or so called attachment behaviour – and attachment experience.  Although we know that attachment relationship is related to later functioning, but we don't know what the pathway is for that.  So compared to social learning theories of behaviour the evidence is really poor.  Just to call something an attachment intervention doesn't mean that it is having an effect through changing attachment.  And indeed, many effective attachment interventions are quite behavioural in focus.  

So it leads us to ask, is an attachment lens actually value-adding in terms of what we want to do to support children's needs in out-of-home care?  And what would happen if we were to park or set aside our ideas about attachment and particularly the drive that we have to set up a primary attachment, a secure attachment.  What would that mean then:  Would that uncover different ways that we could support children in care?  Would it be helpful for example, to recast attachment difficulties in terms of an anxiety disorder,  which then opens up to really sound evidence based approaches that we could support children with?  Would it be better to talk in terms of social learning or trauma integration therapies, which have much stronger evidence base than attachment therapies?

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