Slide outline: Children's attachment needs in the context of out-of-home care

CFCA webinar - 16 November 2016

  1. Attachment in the context of Out of Home Care: What attachment theory can and can’t tell us
    • Dr Sara McLean
    • Australian Centre for Child Protection, Improving the lives of vunerable children
    • Child Family Community Australia, Australian Institute of Family Studies, Australian Government
    • Please note: The views expressed in this webinar are those of the presenter, and may not reflect those of the Australian Institute of Family Studies or the Australian Government
  2. About me …
    • Child and adolescent mental health, challenging behaviour and placement support.
    • Foster care and residential care; theories, programs and interventions.
    • Contributors to behavioural ‘disorders’ of children in OoHC interventions and biological, social and system issues.
  3. Today’s webinar …
    • Attachment –its place in policy and practice in Out of Home Care (OoHC).
      • Attachment theory- what does it say about behaviour?
      • Are there better ways to support children?
      • What are some of the common misunderstandings?
    • What might this mean for decision making in the child’s best interests?
  4. The role of attachment in OoHC?
    • Attachment is arguably the dominant theory in relation to challenging behaviour and child protection practice.
    • Attachment is particularly attractive to clinicians and foster parents (Barth et al 2005; McLean, 2013).
    • Powerful impact of early experiments on attachment that persist today.
    • Is attachment a useful theory for guiding practice and supporting placement stability?
  5. A developmental theory, convergence of evolutionary theory, ethnology, behaviourism and psychodynamic influences.
    • Relevant to the first few years.
    • Emphasis on the biological drive to form attachment; ideally to physically and emotionally responsive, attuned carer(s).
    • It is a one-way bond; seeking of comfort when distressed.
    • Formation of ‘internal working model’ about safety, self and other. Template for later social and behavioural development.
  6. Attachment theory was not developed for children in OoHC
    • Two independent bodies of research into ‘attachment’ and its role in child development.
    • Different aetiologies, different populations.
      • Experimental paradigms using brief separations.
      • Naturalistic experiments following children after institutional neglect.
    • Neither offers evidence that is directly applicable to fostered children, or is applicable across the developmental span.
    • Despite this, they have been influential in decisions about fostered children.
  7. Most attachment is ‘normal’
    • Response to structured assessment protocol involving departure and reunification with caregiver (Strange Situation).
    • Attachment is organised
      • Organised and Secure attachment style–
        • (Free expression of emotion & help seeking, free to explore- optimal internalised view of caregiver).
      • Organised but Insecure attachment style-
        • Avoidant - (Avoids caregiver, minimal distress, emotion overregulated, dismissive)
        • Ambivalent - (Heightened response, emotionally under-regulated, preoccupied)
    • These are all entirely normal (non pathological) attachment outcomes.
  8. Children who could not be classified …
    • Attachment is disorganised
    • Disorganised attachment style - Disorganised representation and using inconsistent strategy (fear without solution). DA more common in maltreatment populations. Disorganised Attachment (DA) is only pattern that is considered problematic. DA linked with later psychopathology and certain caregiving characteristics. Although behavioural observations were key in discovering ‘attachment styles’, we cannot infer a child’s attachment from behaviour outside of this context. A child’s attachment style is not problematic per se.
  9. Attachment in institutional care
    • Categories derived from institutional studies, ‘non normal’ caregiving situations. Diagnosis based on inappropriate social reactions to strangers, rather than to the caregiver.
      • (RAD) Reactive attachment disorder – Disinhibited. Poor social boundaries and marked inability to exhibit selective intimacy. (Now disorder of social engagement).
      • (RAD) Reactive attachment disorder - Inhibited (now RAD of infancy and early childhood) (excessively inhibited and hypervigilent).
    • Both extremely rare. We now know that ‘disinhibited’ attachment disorder is a socialisation disorder, not attachment disorder. Attachment does not account for behaviour.
  10. Attachment in perspective
    • Attachment is a key developmental influence in relation to several aspects of child development (DeKlyen & Greenberg, 2008) although it is only one factor (Rutter, 2009; Shemmings & Shemmings, 2011).
      • Emotional regulation
      • Behavioural regulation
      • Cognitive-affective development
      • Development of social motivation
    • But attachment does not trump other factors such as stability, quality parenting, social connections and opportunities.
  11. But what is the relevance of these ‘disorders’ to OoHC?
    • Disorganised attachment:
      • More common in maltreatment populations, linked to later psychopathology. Specific to a caregiving relationship and temporary. Related to some characteristics of caregiving (fear and availability). But also occurs commonly in normal populations and mostly resolves over time. A ‘state’ not a trait.
    • Reactive attachment disorder:
      • Reaction to extreme neglect and absence of specific caregiver. Two forms of ‘disorder’ but one now thought to have little to do with attachment per se. Disinhibited form not responsive to caregiving but Inhibited form is. Potential role of temperament and other influences on disinhibited type (e.g., FASD).
  12. Could the focus be more effective?
    • ‘Disorder ‘ How common in OoHC? How does this compare? Do targeted interventions exist?
      Conduct disorder ~20-60% >10 x Yes
      FASD ~17-30% >17 x Yes
      ADHD ~9% >3   x Yes
      ASD ~2.6% >1.8 x Yes
      Learning difficulties ~37% ? Yes
      PTSD ~2-4% ? Yes
      Anxiety disorder ~11% ~2x Yes
      Reactive attachment disorder ~1.3-2.0% ~2x No
      Disorganised attachment ~25-50% ~2 -3x (~10-15%) ?
    • Bronsard et al., 2016; Centre for Disease Control, 2016; Lange et al., 2015; ; Meltzer et al., 2004; Out et al., 2009; Vostanis et al., 2007; Winsor & McLean, 2014)
  13. Caveats in the use of attachment theory for OoHC
    • Neither DA or RAD ‘attachment disorders’ offer useful information to support the needs of children in OoHC. Attachment theory is a theory of development and not a clinical theory.
    • Look to factors outside attachment to explain behaviour, Neuropsychological issues related to early life experiences. What are the implications for carers and children if attachment is ‘cause’ of difficulties?
    • Maintain conceptual clarity and avoid concept ‘drift’. This leads to ideas unsupported by evidence e.g., ‘attachment trauma’ and difficult to justify.
  14. Caveats in the use of attachment theory for OoHC
    • Multiple attachments are formed by children at a young age and the pursuit of a ‘primary’ attachment should not be at the expense of a child’s other significant relationships. Family contact decisions are better based on safety, impact on child and child’s wishes than need to foster primary attachment.
    • Foster care is not a child’s first attachment. We know little about the protective features of subsequent attachments and what influences their development (Dozier & Rutter, 2008). Is it realistic to expect a change in attachment status? (Dozier & Rutter, 2008).
    • Culture influences parenting values and concepts of child development.
  15. Caveats to the use of attachment theory for OoHC
    • Our knowledge of attachment is limited to the first few years. We know relatively little about how attachment develops and its relative importance in school age children.
    • Attachment theorists do not state a causal relationship between attachment and later development, rather that it forms a template for later development.
    • Evidence based attachment interventions are focussed, time limited and age appropriate , focusing on parental sensitivity (Bakermans-Kranenburg , van IJzendoorn, & Juffer, 2003). - is this what we are delivering?
  16. How can we support children more effectively?
    • There is little support for the idea that behaviour disorder is attachment related; although there is a relationship between attachment status and later well being it is multidetermined.
    • There is very little evidence to guide ‘attachment interventions’ beyond early childhood.
    • Is an attachment lens the most practical and clinically useful explanation for behaviour and placement difficulties when compared to others?
    • If we set attachment beliefs aside, what other ways can we offer support to children in care?
  17. Questions?
    • Join the conversation & access key resources
    • Continue the conversation started here today and access related resources on the CFCA website:  www.aifs.gov.au/cfca/news-discussion

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