When you take on the psychotherapy role with a child or young person who is recovering from as tough start to life in out-of-home care, there is a real possibility that you will become the most consistent and enduring adult in their life, and of the therapeutic relationship being the most reparative one.
In such circumstances, it is difficult to bring therapy to a therapeutic close, and the child or young person will actively resist and protest this. Some service providers will not even start therapy in circumstances where this might occur, such as among children and young people in residential care, or those with a history of placement changes and breakdowns.
I draw reassurance from the “one good adult” literature and evidence base. Better that the child or young person has/had at-least one good adult in their life. Better again if they also have reparative contact with birth parents/family, stable therapeutic care, stable trauma-informed education placement, and opportunities to form reparative relationships with adults beyond the home and education settings (eg sporting clubs, scouts, cadets, etc).
When these further opportunities for reparative relationships occur, therapy can be meaningfully and therapeutically (and carefully) brought to a close without triggering renewed feelings of grief and loss for the young person, and associated trauma-based responding.
So, therapy must include and/or support endeavours to provide children and young people with opportunities to develop other enduring, sensitive, and responsive relationships through supported (re)connection with birth family, stable therapeutic care placements, trauma-informed care and management in school, and opportunities to engage successfully in community activities.
Ultimately, we need to make ourselves, as therapists, redundant!
What’s in a name? The image above was taken six years ago. Sadly, I don’t look quite the same these days! I am photographed, here, with the second edition (published December 2016) of one of my books, which was first published back in 2009. The second edition involved considerable revision of the first edition, as the content of the first edition derived from my writings on the topic between 1999 and 2009. In the period from 2009 to 2016 my thoughts on the topic of the book developed in significant ways. Similarly, if I was to work on a third edition, I daresay there would be further important revisions.
One revision I would like to make, if I was able to do so, is to the title. I would substitute ‘disorder’ with ‘trauma’, as I think that this would better reflect the content of the book. While there is content about Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in the book, the formulations and reparative caregiving and treatment guidelines are relevant to children and young people who have experienced attachment trauma more broadly, including those children and young people whose grossly inadequate care is variously described as relational trauma, early trauma, developmental trauma, and/or complex trauma.
I would also like to make it clear in the title that there are guidelines for caregivers and professionals, including reparative caregiving strategies and a treatment approach.
Moreover, I would like to further avoid giving the impression that attachment trauma invariably leads to an attachment disorder diagnosis; though there are times when RAD and DSED are appropriate assessment formulations and guides for therapeutic supports (albeit, RAD and DESD are rare disorders).
So, with the passing of time the book, like my appearance, would look different; albeit that much of what is in the book remains relevant to readers interested in attachment trauma.
For more information about my books, including how to purchase them via my affiliate links, please click the image in the side menu.
Conventional responses to behaviours of concern, such as reward and punishment strategies, are widely considered to be ineffective in addressing the complex and challenging behaviours exhibited by children and young people who have experienced complex, relational, or early/developmental trauma. This is because a number of the preconditions for reward and punishment strategies to work do not exist among these children.
For example, in order for rewards to work, the child or young people needs to believe, based on prior learning, that you will follow through with the promised reward if they exhibit desired behaviour (or inhibit undesirable behaviour). Children and young people who have experienced grossly inadequate care find it hard to trust that adults will follow through with their promises. Rather, they expect to be let-down and are not motivated to work to achieve a reward, instead believing that that they are unlikely to be successful and you won’t follow through anyway.
Further, children and young people who have experienced abuse and neglect view punishments as further evidence of their inherent badness and of the meanness of adults. Rather than being motivated to comply with behavioural expectations to avoid punishment and maintain positive relatedness, they strongly hold on to their beliefs that they are inherently bad and unlovable and that adults are mean and uncaring. They persist in their behaviour of concern because it satisfies a need, including the need to feel like they can influence what happens in their world. They do so without consideration of the impact of their behaviour on their relationships with others, because they don’t expect to have good relationships, especially with adults in a care and management role, anyway.
Responding to behaviours of concern exhibited by these children and young people requires a different approach. It requires us to acknowledge and accept that all behaviour occurs for a reason. If it did not achieve a desired outcome when it was first exhibited and at-least sometimes thereafter, it would have been dropped in favour of a more successful behaviour. It then requires us to consider what the reason for the behaviour is and respond to that in a way and until the behaviour stops or is exhibited at more normalised frequency, intensity, and duration. This is the therapeutic response to complex and challenging behaviours exhibited by children and young people who are recovering from a tough start to life.
The decision to remove a child or young person from the care of their birth parents is a grave one that confronts child protection authorities daily. Removal occurs with the intention of protecting the child from harm and securing their safety. The wider community expects child protection authorities to intervene to protect children from harmful circumstances and secure their care and protection. Indeed, child protection authorities are often subject to intense media scrutiny and community outrage in circumstances where they are perceived to have not intervened to protect a child, and the resultant harm becomes known to the community.
There is positive intent in removal. But what are the negative impacts, if any, of this well-intentioned action to secure a child’s safety and protection from harm?
An intriguing group of children are those who are removed from the care of their biological parents at or very close to birth, and who remain in care long-term. Carers of these children are often perplexed when, years later, and notwithstanding loving care afforded to them, the children show many of the same complex and challenging behaviours commonly observed among children who have experienced abuse and/or neglect prior to their removal. This has led to consideration of the impact of pre-natal trauma on the developing child. However, my experience has taught me that there is another valid line of enquiry into why children removed at or close to birth exhibit maladjustment not dissimilar to those who are removed later, and which provides an insight into the potential negative impact of removal more generally.
Irrespective of when they are removed from the care of their birth parents, children who remain in out-of-home care appear to suffer from difficulties in the areas of self-worth, identity, and belongingness which, in turn, result in complex and challenging relational behaviour. When they are old enough to do so, these children and young people speak of a profound loss associated with not having had the opportunity to be raised within their birth family. They question their worth in relation to this. Why could their birth parents/family not make more of an effort? Didn’t they love me? Am I unlovable?are common insecurities. Who am I? and Where do I belong? are others.
As they seek answers to these questions through behaviours that are experienced by their caregivers at home, in school, and in other domains of their life as perplexing and challenging, these questions crystallise into an enduring sensitivity about self-worth, identity, belongingness, and relational connection. In turn, this sensitivity manifests in:
Too often, the reaction of well-meaning adults to these aspects of the child or young person’s approach to life and relationships only confirms and reinforces their fear that they are worthless and unlovable, and maintains maladaptive behaviour and identity concerns.
So, what is the answer?
My experience has taught me that we engage with and support these children and young people in ways that promote their self-worth and belongingness as a vital priority. Unfortunately, this can be a ‘double-edged sword’ as the more they are loved the more disappointed they feel about those who they perceive did not (or do not) love them enough; potentially compounding the issue.
In addition to engaging with these children and young people in ways that support their worthiness, identity, and belongingness, there needs to be greater recognition of the enduring role and importance of birth parents and family after removal. There needs to be greater recognition of the negative effects of removal, which present as an enduring sensitivity about worth, identity, belongingness, and connection to others.
Removing children often results in a worsening of the pre-existing maladjustment of birth parents as their own worth is eroded by the removal and associated reasons for it. Where it is possible and safe to do so, child protection authorities need to meaningfully engage birth parents in recognition of their enduring role and importance in the life of the child, and support the maintenance of best connections between the children and their birth parents/family.
As John Bowlby once wrote: If we value our children we must cherish their parents.
It is not anticipated that this is or will be easy. Community sentiment, echoed in the media, often asserts that child protection authorities need to remove all children at risk and give them the opportunity to grow up in a place of safety. My experience has taught me that support of an enduring connection with birth parents/family represents the best chance of meeting community expectations about outcomes for children and young people in need of protection and care.
In this the final blog of the series, I will present what I think functional learning about the accessibility and responsiveness of adults in a caregiving role for needs provision looks like. I recommend that the reader also take a look at the previous blog posts in this series, which can be accessed below:
Children and young people who are recovering from a tough start to life often present in a manner that reflects that they are unsure about, or don’t trust, that adults in a caregiving role will be accessible to them, understand their needs (and reasonable wishes), and respond to them in a consistent and predictable manner. This manifests in inordinately demanding behaviour, of caregiver proximity and responsiveness, and/or inordinate self-reliance. Sometimes, they alternate between the two. Their caregivers typically feel overwhelmed and frustrated which, in turn, often leads to withdrawal, restriction, and further unresponsiveness; the impact of which is worsening of the child or young person’s preoccupation with accessibility to needs provision.
This problem behaviour arises because of what the child learns about the accessibility and responsiveness of adults in a caregiving role during the early developmental period where caregiving is inconsistent and inadequate. These children and young people typically learn that you cannot always rely on adults in a caregiving role when their care was adversely impacted by addiction, mental health difficulties, relationship issues, and poor parenting knowledge.
Children and young people who are recovering from a tough start to life benefit from care that supports new learning that adults in a caregiving role can be relied upon to be accessible and responsive to them. To learn more about caregiving strategies to achieve this I refer the reader to A Short Introduction to Attachment and Attachment Disorder (Second Edition).
Evidence that the children are making this new learning includes acceptance of proffered care, exploration of their world, being able to share with others, age-appropriate dependency, acceptance of temporary separations, independent play, and age-appropriate independence, including with self-care routines.
I cannot underestimate the importance of knowing what success on behalf of children and young people in our care who are recovering from a tough start to life looks like, and have included below and table for quick reference based on the Triple-A Model (Pearce, 2016, 2012, 2011, 2010).
| Arousal | Attachment | Accessibility (to needs provision) |
| Calmness | Giving things a go | Accepting separations |
| Restful sleep | Confident exploration | Sharing |
| A range of natural emotion | Joining in | Seeking help when needed |
| Easily soothed | (Appropriate) Independence | Independent play |
| Cooperation | Accepting Challenges | Exploration |
| Sustained attention (focus) | Seeking help when needed | Feeding self |
| Bladder and bowel control | Having fun | Independence |
| Attaining milestones | Making friends | |
| Academic success | Accepting Challenges | |
| Grooming | ||
| Using words to communicate | ||
| Positive self-esteem |
If you enjoyed this series and would like to write about topics related to child protection, therapeutic care, and psychology service provision, do get in touch.
References:
Pearce, C.M. (2016) A Short Introduction to Attachment and Attachment Disorder (Second Edition). London, Jessica Kingsley Publishers
Pearce, C.M (2012). Repairing Attachments. BACP Children and Young People, December, 28-32
Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London, Jessica Kingsley Publishers
Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86
Pearce, C.M. (2009) A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley Publishers
In this, the third blog in this series, I will write about what a well-modulated nervous system looks like among children and young people who are recovering from a tough start to life. Please also refer to the first and second blogs in this series, which can be accessed here and here.
Children and young people who are recovering from a tough start to life typically exhibit behaviours associated with an over-activated nervous system, or hyper-arousal. This can manifest in difficulty sleeping, emotional reactivity, and motor restlessness. Coupled with their proneness to approaching life under the influence of negative beliefs about self, other, and world (AKA attachment representations, or internal working models – refer to the second blog in this series) these children and young people are prone to anxiety and behaviours associated with the fight, flight, freeze response, including:
Unfortunately, these behaviours are not always understood to be non-volitional responses to activation of the nervous system’s in-built survival response. Rather, they are often seen simply as bad behaviour, and responded to with anger and disapproval. This only serves to further heighten arousal and confirm the child or young person’s belief that they are bad and unsafe and that others are threatening, leaving them even more prone to future anxiety and behaviours associated with the fight flight freeze response.
We are very good at noticing these signs of a nervous system under stress or duress; albeit that we don’t always see it for what it really is. Harking back to the first article in this series, we are comparatively less likely to recognise evidence of a well-modulated nervous system. If we are not looking for evidence of a well-regulated nervous system, we are likely to miss signs of it, with the result that we continue to notice and respond disproportionately to so-called problem behaviour, to the detriment of the child’s emerging self-image and our own feelings of competency in a care and management role.
So, what does a well-modulated nervous system look like? Children and young people who have a well-modulated nervous system experience longer periods of wellbeing and a range of natural emotions that are congruent with context and [easily] self- or co-regulated (that is, able to be regulated with the assistance of an attuned adult). They perform better in learning tasks and other tasks of daily living. Their developmental progress is within normal limits, or near to. They explore their world, including relationships, unhindered by anxiety. They sleep well and have less sensory issues. They are accepting of adult authority, and comparatively easy to get along with.
So, look for the signs of a well-modulated nervous system. You are more likely to feel optimistic about the future of the child or young person. They will, in turn, feel more positive about themselves.
For a more comprehensive introduction to my work, including a ways of supporting recovery from a tough start to life in the home, classroom, and consulting room, I recommend accessing A Short Introduction to Attachment and Attachment Disorder (Second Edition).
In the final blog of this series, I will present what the third aspect of the Triple-A Model (Accessibility to needs provision) looks like.
In the first blog of this series about child welfare intervention outcomes, I wrote about the importance of knowing, and being able to say, what progress toward successful outcomes looks like. In this second blog of the series, I will talk about what attachment security looks like.
Before I get into it, I want to make the point that I am not talking about the reduction in a behaviour or behaviours of concern, or symptom reduction. This is still ‘problem-focused’, with the same associated difficulties as I highlighted in the first blog. Rather, I am taking about what progress towards recovery looks like for children and young people who are recovering from a tough start to life.
In the first blog in this series I referred to the Triple-A Model (Pearce, 2016, 2012, 2011, 2010), which I use as an explanatory framework for understanding the impact of early relational trauma on the developing person. The Triple-A Model refers to Attachment, Arousal, and Accessibility to Needs Provision. These constructs also help us to reflect about and identify what progress towards recovery from early relational trauma looks like. In this article I am going to refer to the first construct, attachment, and what progress towards attachment security looks like.
Early relational trauma negatively impacts attachment security in the developing child and, in turn, their approach to life and relationships. This is, perhaps, best represented in the internal working models, or attachment representations, that develop in the context of our early attachment experiences. These take the form of beliefs that, mostly subconsciously, influence our approach to life and relationships. They are the beliefs that are held about ourselves, others, and the world in which we live.
Among children and young people who have experienced early relational trauma, the attachment representations that influence their approach to life and relationships are predominantly negative. They believe themselves to be bad, unlovable, unworthy and incompetent; they believe adults in a caregiving role to be unresponsive, uncaring, and unsafe; and they believe that the world in which they live is a harsh and dangerous place. They approach life and relationships under the influence of these beliefs, and this is reflected in their behaviour. That is, their behaviour reflects their inner world and the beliefs they hold about themselves, others, and their world.
In contrast, children who were raised in safe and nurturing homes predominantly approach life and relationships under the influence of secure attachment representations. They believe themselves to be good, worthy and capable; adults in a caregiving role to be accessible, responsive, and safe; and they believe their world to be safe and full of opportunities. Their behaviour is largely consistent with these beliefs.
In consideration of the above, when intervening to promote recovery from early relational trauma, we need to turn our mind to what needs to happen to strengthen the influence of secure attachment representations over the young person’s approach to life and relationships. As their behaviour reflects their inner world and attachment beliefs, we need to know what behaviour that is under the influence of secure attachment representations looks like.
In my work with children recovering from a tough start to life, the first thing I look for is that they are making some effort in relation to their appearance. Self-care reflects self care. I also look for natural interest in engagement with me and comfort in separating from primary caregivers. I look for positive and realistic self-appraisals and acceptance of praise. I look for awareness of the experience of others and regulation in consideration of others. I look for a transition from behavioural expression to verbal expression about their needs and experiences. I look for preparedness to try new things and tolerance of frustration and failure. I look for emerging interests and participation in related pursuits. I look for persistence in their endeavours born out of a natural desire to be successful. I look for interactions with me that reflect my role and endeavours with them. I look for choices and actions that reflect a positive sense of their worth. I look for anticipation of a career, of enduring relationships, and of a family of their own.
In addition, I am keen to hear about the following aspects of the child’s approach to life and relationships, and I encourage adults who care for or have a caring concern for these children and young people to look for them too:
There are other signs of progress towards recovery from early relational trauma, but these also reflect well-modulated arousal and functional learning about accessibility to needs provision, so I will include these in the next two articles in this series.
For a more detailed representation of my knowledge and work with children and young people recovering from a tough start to life I would be pleased if you would access A Short Introduction to Attachment and Attachment Disorder (Second Edition).
References:
Pearce, C.M. (2016) A Short Introduction to Attachment and Attachment Disorder (Second Edition). London, Jessica Kingsley Publishers
Pearce, C.M (2012). Repairing Attachments. BACP Children and Young People, December, 28-32
Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London, Jessica Kingsley Publishers
Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86
Pearce, C.M. (2009) A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley Publishers
Some know that while attaining my post-graduate qualifications in Psychology I worked for five years as a Research Officer in the local Child and Adolescent Mental Health Service (CAMHS). During this period I worked closely with Psychiatry staff who were both expert practitioners and avid scientists. Looking back, I believe more and more in the importance of expert practitioner’s also conducting research in their areas of practice expertise. Who better to lead research into a field of endeavour than expert practitioners in that space?
I then look at where my own career has taken me, in the field of child welfare. My experience has been that there has not ever been time or allowance to conduct research into the field of endeavour in which I (and many others like me) have built significant expertise through practice. Rather, much of the research that we rely on comes from the academics with a special interest in our area of endeavour.
This is more and more concerning to me, especially in an era where evidence-based practice is the “gold standard”. Where does that leave expert practice built upon years of endeavour working directly with children, young people, and all who play a role in the domains of their lives? What status is accorded to practice expertise? Compared to that which comes out of a university study, I would say less status.
Ideally, expert practitioners in the field of child welfare would have time and allowance to be involved in research into best practice and practice knowledge. There is no substitute for conducting the assessment, making the recommendations, implementing the treatment plan, and reviewing the outcomes across one, or two, or more decades of practice, I believe.
Child welfare leaders and academics with a special interest in knowledge and practice in child welfare, it is time to engage practice leaders in research in child protection and child welfare.
(Please note that my reflection is largely based on my observations and experience in the jurisdictions in which I have worked. If the situation is different elsewhere, I would greatly appreciate hearing from you!)
What outcomes do you expect to see as a result of my service provision?
This is a question I routinely ask in my work. Put another way:
These are, perhaps, the fundamental questions that get at the hopes of the engaging entity.
Yet, I have found that these are some of the most difficult questions for the engaging entity, be that a parent or other caregiver, a representative of a school, or a representative of child welfare organisation, to answer.
In straightforward terms, it has been my experience that engaging entities find it very difficult to express what successful outcomes look like.
Why might this be the case? The answer lies, in part, in what we typically attend to as we negotiate our lives and our roles.
Humans are, first and foremost, problem solvers. Problem solving has allowed us to successfully negotiate a myriad of challenges and successfully adapt to our living conditions through history and in our contemporary world. As an illustration of this, when I show the image below during training or supervision, and ask my audience what is the first thing they notice, they almost invariable identify the simple maths equation that is incorrect, in the bottom left corner. No-one, and I have been using this graphic for several years, has ever said that nine of the equations are correct.
No-one has ever said that nine of the equations are correct.
We instinctively notice problems and are very good at saying what they are. We are also very successful, as a species, in solving them, However, in my experience working in child welfare and psychology service provision in this field, where problems abound, there is a manifest difficulty in being able to say what a good outcome of an intervention or process looks like.
The danger here lies in missing the evidence of success in our endeavours. Why? Because child welfare work can be overwhelming. If we miss the evidence of our successes and focus selectively on problems to solve, we are vulnerable to feeling like a failure in our role, and give up. Further, as children and young people see themselves as they experience others to see them, our selective focus on problems results in them seeing themselves as a problem.
Even in writing this article I am guilty of the same selective attention to problems; in that the inordinate focus on problems is a problem!
We need to get better at knowing what success in our endeavours looks like; in responding to the questions posed at the beginning of this article. The knowing supports thinking which, in turn, supports noticing. The noticing supports self-efficacy and identification of effective interventions. Noticing progress and success supports a healthy self-image among children and young people who are recovering from a tough start to life.
During the Kinship CARE Project, which ran from 2018 to 2020 as a training initiative of Secure Start with support from the Department for Child Protection, South Australia, we collected data about a range of outcomes, from attendance data to satisfaction with the training and the like. However, perhaps the most heartening data was the proportion of participant kinship carers who reported feeling more confident in the role as a result of their participation in the Project.
Similarly, in the implementation of the Triple-A Model of Therapeutic Care in the TUSLA Fostering Service in Donegal, Ireland (soon to enter its eighth year of continuous implementation), the most heartening outcome is the longevity of the implementation, the sustained interest of local general and relative foster carers, and the extension to the implementation of a complementary training program in local schools over the last 18 months.
In my clinical work with children and young people who are recovering from a tough start to life I reflect particularly on the Triple-A Model and what positive outcomes in terms of attachment security, arousal modulation, and functional new learning about accessibility to needs provision look like, as reflected in the graphic below which is drawn from a number of my programmes:
In the next article in this series I will write about more what a secure attachment style looks like and, thereafter, about what a well-modulated nervous system looks like and what functional learning about access to needs provision looks like.
References:
Pearce, C.M. (2016) A Short Introduction to Attachment and Attachment Disorder (Second Edition). London, Jessica Kingsley Publishers
Pearce, C.M (2012). Repairing Attachments. BACP Children and Young People, December, 28-32
Pearce, C.M. (2011). A Short Introduction to Promoting Resilience in Children. London, Jessica Kingsley Publishers
Pearce, C.M. (2010). An Integration of Theory, Science and Reflective Clinical Practice in the Care and Management of Attachment-Disordered Children – A Triple A Approach. Educational and Child Psychology (Special Issue on Attachment), 27 (3): 73-86
Pearce, C.M. (2009) A Short Introduction to Attachment and Attachment Disorder. London, Jessica Kingsley Publishers
Attachment and Resilience 