In the following interview between Professor Helen Minnis from the University of Glasgow and David Woodier a teacher, adoptive parent and blogger for Scottish Attachment in Action, Helen speaks about 'Why Attachment Matters' to her. Themes emerging from the interview may well resonate with those living and working with children and young people who’ve had an adverse start in life.
… I can’t help feel I have been gifted,
Lifted out of darkness,
Carried by angels to a safe place,
A haven with four windows,
And a single door,
The most beautiful place in all the world,
With the most beautiful people to welcome me, … 1
How do we create a world that is safe for children who have suffered abuse and neglect? How do we help them thrive in relationships? The words above are from a poem of a child who was adopted. The question for those of us who live and work with children who have suffered maltreatment is, how to put what we know about attachment into action. In the following interview, Professor Helen Minnis talks about her passion for helping children and young people. She discusses a range of issues, from teenagers to new therapeutic approaches, and from brain development to helping children cope with separation and loss.
When did your interest in attachment begin?
I wanted to do psychiatry, but before I wanted to do psychiatry, I wanted to travel. I spoke to the head of Child and Adolescent Psychiatry at the Maudsley Hospital. I said, “I am going to Guatemala for a year to work in an orphanage. What would you suggest I think about?” He said, “You should think about attachment and attachment disorders,” and he gave me the draft of the psychiatric classification system for attachment disorders. That was where my interest was born. That draft talked about children who had been abused and neglected being indiscriminately friendly on the one hand, and on the other hand, some of them being withdrawn and failing to seek comfort. I arrived at the orphanage and saw that right in front of my face. I was literally covered in children under five. I couldn’t walk forward until I peeled their little hands off. I became passionately interested in attachment.
Is Scotland a nurturing place to grow up? Are children able to build healthy attachments here?
It is all relative. In terms of encouraging the public to think about attachment the Scottish Government is quite far ahead. I remember a few years ago there were billboards, paid for by the Scottish Government, of a big sponge and the words: This is Your Baby’s Brain. I also think we realize we have some really big problems, and one of the big problems is the way we treat our teenagers. I think we ignore them; we don't give them eye contact; and we don’t give them a role in society. There are some major things we could do to make Scotland a more nurturing place, but it is great to live and work in a country where that’s what we are aiming for.
When did you first become involved with the work of Scottish Attachment in Action and why does an organization like Scottish Attachment in Action need to exist?
I was involved from day one. We had the Attachment Reference Group in Glasgow for colleagues from different disciplines to come along and discuss attachment. Edwina Grant heard about what we were doing, and we organized a day when we brainstormed about what Scottish Attachment in Action should look like. It was an incredibly exciting day, because we discovered that although we were from such different disciplines, we were really talking the same language. We realized was there was a need for a common language about attachment particularly across front line services that work with children including police, teachers, and nursery nurses. There was a role for both training and advocacy. I think Scottish Attachment in Action tries to sit in that space. It is always going to be needed, because getting people to think about young children is tricky. It is very hard for adults to put themselves in the mind of a child, because it is a long time since we were children. I think it is something that needs to be a daily struggle.
A number of years ago, you looked at the mental health of a group of adopted children living in Scotland. What effect does nurturing care and a stable family life have on children who were maltreated early in life?
It makes all the difference. Adopted parents have known that. I remember being sharply told off many years ago because I used the term “natural parents” which was an old term people used to use for birth parents, and someone said, “Adopted parents are natural parents, because they have done the nurturing.” That is so true. A child comes into the world with their genetic hand of cards, and what happens to that genetic hand of cards depends so much on the nurturing they receive from their family. From the study of epigenetics, for example, we know that the environment that surrounds the child can modify the DNA. Nurturing from parents is so crucial.
If we were to look inside a child’s brain, that of a child who suffered maltreatment early in life. What are some of differences nurturing care can make?
We don’t know more than we do know. The brain is like an unexplored landscape. One of the reasons I am in child and adolescent mental health is because we know less about the brain than we know about the universe. We know that the frontal temporal lobe of the brain, the sticky-out bit at the forehead, is bigger in humans. That’s because we need more in terms of planning and social interaction. Children who suffered early neglect and maltreatment sometimes have problems with some of the functions particularly associated with that part of the brain. Nurturing care can help children inhibit some of their emotional responses. Learning to plug into other special people by being part of a family and having the world interpreted for you by your parents, older siblings, and gran etc. is really important.
There are some children who seem to resist connecting with that nurturing care. Is there anything to understand about how children build attachments that could help us reach out to these children?
One of the things we have become more interested in is faulty signaling. This is when neglected children, because of their early experience of neglect, have learned to manage their own world so they habitually don't reach out to parents and carers. They fundamentally don’t understand that parents and carers are there to help you, support you, and comfort you when you are stressed. John Bowlby, who developed attachment theory, described how right across species it is a profound instinct to reach out to your carers when you are, for example, stressed, frightened, or have a tummy ache. It is actually a really small minority of abused and neglected children who don’t reach out. These children are then missing out on huge swathes of normal development. One of the really fantastic things is that in about ninety-nine times out of a hundred if neglected children are placed in loving families early in life that lack of signaling disappears quite quickly. However, there is a tiny minority of children in which it doesn’t melt away. I don’t know if that has something to do with the constitution of the children themselves or whether it has to do with not having the opportunity to be placed in a loving family soon enough. There is a tiny minority of children who, even in teenage years and adulthood, just don’t get that they should be reaching out.
I have noticed that some children with difficult starts in life -- children who don’t seem to respond well to the nurturing care of a foster carer or adoptive parent -- appear to ‘sort things out’ during adolescence. Is there something going on developmentally, a kind of re-wiring of the brain, that allows a young person to see things in a different way?
We know there are two rapid periods of brain development in life, the first few months and years of life and then again in adolescence. In adolescence the axons of the brain -- the long connections between your brain cells -- are being ‘cladded’ with myelin sheaths. It is a bit like cavity wall insulation. This is not something I am an expert on, but I have heard it used to explain why a child who is quite articulate at nine years old seems to almost lose the power of speech when they reach twelve. There is a lot going on in the brain that they are concentrating on. It is recognized that it is a time of opportunity because there is so much plasticity, so much of an opportunity for change and new development in the brain. One of the things that always gives me hope is that we now know you can develop new brain cells even in old age. The brain is different than other organs in the body. When you are born, your heart looks like it looks when you are an adult; it is just a small version of what it will be when you grow up. That is not true of the brain. When you are born and then again in adolescence, the brain has a huge amount of sculpting to be done. It is also worth remembering that some people heal and recover even later than that. I have personal stories of adoptive children who have left home at the age of sixteen and said, “I am never going to darken your door again.” Then they turn up later. I have a family friend whose son came back at his adoptive mum’s seventieth birthday party. He had been in prison and was covered in tattoos from head to toe. Now he is a loved member of the family again. So, although you are right that there are opportunities in teenager years, there are later opportunities as well.
You have been piloting something called the New Orleans Intervention Model in Glasgow. Could you say something about what makes this model different to services-as-usual for children and families?
There are two big differences. One, it is an infant mental health model. The other difference is that it offers treatment to birth families so that it is not just an assessment model. It was developed by Professors Charles Zeanah and Julie Larrieu from Tulane University in New Orleans. For a long time in New Orleans, every child who came into foster care under the age of five was offered this model. It offers standardized, attachment-based assessments in each of their caregiving relationships. They also do interviews and questionnaires with the birth parents about their own experience of attachment and caregiving, and refer the birth parents for help. For example, if they have problems with substance misuse or domestic violence. That process takes about three months, and then there is a period of intensive treatment with the aim of changing the birth family’s relationships so they can get the child home. But if it doesn’t work within a time limit, then the child is recommended for adoption.
Has any aspect of the study surprised you?
We have learned a lot about the nature of our systems here in Glasgow and about the ways in which we inadvertently cause delays for children. I think it has a lot to do with our difficulties as adults in putting ourselves in the mind of a child. There are so many places through a child’s journey where adults from all sorts of professional backgrounds could have thought, ‘This is not right for this child, and we need to move this forward,’ but we don’t. It has been a surprise at what kind of a perennial, entrenched problem that is.
Would there be a benefit in Scotland if we follow the example of some parts of the US where foster carers are also recruited to become prospective adopters?
One of the things we have become interested in through this project is the nature of foster care. Mary Dozier from Delaware has talked about commitment in foster care and whether the commitment comes from the length of a foster placement or from the freedom foster carers are given by their manager to fall in love with the child. In the United States, foster carers usually join the register as adopters. The philosophy behind that is that foster carers are supposed to be totally child centered, to love and commit to the child and potentially be the child’s forever parent. But if the birth parents get their life back on track, then the foster carers will have to relinquish that child. Some people say to me that it must be awful for the foster carer, but can you imagine that is generally what we do to children. The system in the United States allows the adult to take the hit rather than the child, and it seems to work well. Certainly in New Orleans it reduces delays. It means you are also not building in a loss for the child.
It is still a reality in the UK and in Scotland that children who are looked after are often moved around. They experience new foster parents, new schools, and new social workers. How do we help children who form multiple attachments? For example, should a child who is adopted visit their previous foster carers? Should a young person who is unexpectedly moved to a new school over the summer holidays have an opportunity to say goodbye to his teacher at his old school?
Those are examples of attachment in action. They are examples of being child centered. In a family where there has not been disruption through abuse and neglect and placement moves, that is what you would do for your child. For various reasons at the age of four, my daughter had to move, and we made a goodbye cake and we visited everyone. That is what you do because you nurture your children’s attachments. It is about nurturing children’s attachments and recognizing that secure attachments can come from surprising places. A child who has had a difficult early start may have a secure attachment with someone like their teacher, and that has got to be recognized.
Some people are concerned that contact, for example, with a previous foster carer, will prolong a child’s sense of loss and that it might make it more difficult for a child to form an attachment to a new family.
Probably the most important thing is to try and tune into the child. Try and understand that a child is likely to be grieving. Children go through bereavement processes in the same way that adults do. Relationships shift for children, and that is not a reason to pretend they don’t exist. Once a child is placed with a forever family, and the child understands that they are in a family who are committing to them for the rest of their lives, contact with a previous foster family can be very positive. This is very different than the situation where you have, for example, quite a damaged birth parent. I am not suggesting all birth parents are damaged. But if, for example, you had a birth parent where the experience for the child visiting the birth parent is really traumatic, then that needs to be thought about in a child-centered way. Difficult decisions have to be made. Children should not be allowed to see people who may have a negative effect on the child’s development.
Children with attachment difficulties often struggle to get the right kind of support in their schools. Can you talk about some of the reasons for this? Is it because children with attachment issues often present a variety of difficulties, and that makes it harder to identify that there may be an underlying attachment issue?
I think there is a lot in that. Identification is a problem. Particularly if they have attachment disorders, children with attachment issues nearly always have other problems. That is confusing, not just for teachers, but also for parents and clinicians as well. We know something we didn’t know fifteen years ago, if children or adolescents have one mental health problem, they are more likely to have others. We used to say, for example, if you have ADHD, then it can’t be anxiety. We know now that wasn’t sensible at all. Children with ADHD are at higher risk, for example, of having problems with autism or vice versa. Children who experienced early neglect and abuse are at higher risk than the general population of having other neurodevelopmental problems. This is some data we have found, and other people have found this, too: children who have had early neglect and abuse and have mental health problems often have complex neurodevelopmental problems. How these problems can be identified in school is really difficult. On the plus side, educational psychologists in Scotland are on the ball with this. I think they have led the way in thinking about attachment in schools and helping teaching staff think about attachment.
We are in the process of trying to develop something called the School Attachment Monitor, SAM. In the last six months, I have been working with Stephen Brewster and Allessandro Vinciarelli from Glasgow University School of Computing Science. SAM will be like a computerized version of the Manchester Child Attachment Story Task. If it works it will be automatically rated which means that it can be used in schools and we can look at the profile of attachment in children in the classroom.
I have heard carers, adoptive parents, and social workers express frustration with the mental health services available for young people in Scotland. Is there a mismatch between the needs of our children and what is offered to families? Is there something we can do about that?
Sometimes it is a problem of not recognizing the complexity of problems children experience when they have been maltreated. I have a lot of sympathy for my colleagues. Many do recognize the complexity, but I think we have all been on a really steep learning curve. We have done some research recently that suggested the direction of travel may not be what we thought it was. We know that a lot of ADHD has genetic causes, but I had always thought another route into ADHD was maltreatment. From some of the data we got recently, it is starting to look as though it might be the other way round. Children with some of these neurodevelopmental problems, in families that are already struggling, might be more likely to be maltreated. Therefore, in a sense, many maltreated children have a double whammy. This is new information for child and adolescent mental health services. In the past, we used to see children who had been maltreated and think that it is no wonder they have conduct problems, problems with behaviour. In fact, we should be thinking we really need to assess these children carefully. They may have genetic loading towards some neurodevelopmental problems that are going to make them more difficult to look after in the first place, not that there is ever an excuse to maltreat a child. The understanding of the complexity of these children hasn’t been there in our profession, but we are getting there. The other big issue is there are not enough of us. There are far too few child and adolescent mental health clinicians. Something parents could do is lobby. My clinical colleagues are genuinely overwhelmed.
You have been looking at the feasibility of DDP -- dyadic developmental psychotherapy2-- as a treatment for maltreated children in the UK. What is it about DDP compared to other approaches that makes it worthwhile considering the relatively high financial cost?
I think it’s worth considering, because it is different to existing psychotherapeutic interventions for children who have experienced abuse and neglect in that it promotes what Mary Dozier calls ‘a gentle challenge.’ Old-fashioned psychotherapy is very much led by the child; the child leads what happens in the room and the psychotherapist follows. That is sensible for the great majority of children, but if you have children that don’t signal their needs, that kind of child-centred approach is maybe not going to be successful. What I like about DDP and what gives it potential is the idea of PACE: playfulness, acceptance, curiosity and empathy. The PACE stance is a bit more gently challenging; you are not letting the child get away with hiding under the table and not engaging in therapy. In a playful, accepting and curious way, you are going to be saying, “The things that happened to you in the past are probably what’s making you sit under the table, but you have these good parents here who are ready to give you a good snuggle, so come and experience the love that’s available for you.” It's more directive in a gentle way. We also know from our research that therapists who are using it are very enthusiastic. So I think it has a lot of potential and needs a trial.
What are the barriers to seeing a wider availability of DDP in the UK?
One of the things the NHS should be proud of is that we carefully review the evidence base for those interventions. We haven’t yet got a robust evidence base for DDP. We need randomized, controlled trials if it is going to be commissioned.
Over the last ten years, there has been a resurgence of interest in attachment. Training on attachment is popular; it has almost become a buzzword. But are we really putting attachment into action?
I think so. It is a bit of a double-edged sword. I was at a meeting in England a couple of years ago with lots of social workers and academics. I think I was the only child and adolescent psychiatrist. People were saying, “All this early years stuff and attachment stuff; it is kind of flavor of the month.” I was thinking “Sorry!” So there are, in some circles, people who don’t see the importance of it. But again, that is one of the reasons I am happy to be living and working in Scotland because we have developed a shared language. Scottish Attachment in Action has to be patted on the back for that. There are other groups working towards a much more nurturing place to live. For example, it is wonderful that in education we now have this idea of, ‘How Nurturing is Our School?’ This is not some kind of soft option or some wishy-washy place. If we are nurturing children, they can thrive, and they can do well emotionally, behaviourally, and in their attainment.
But isn’t there a problem that attachment can remain too theoretical and abstract? Our understanding of attachment still does not make enough of a difference in how we make decisions; for example, in the way we work with a child who is being disruptive in school and being threatened with exclusion. Are we underestimating the difficulty of how to put what we know about attachment into practice?
There is a problem: attachment has been very laboratory based. The measures recommended for use in clinics are too cumbersome. For example, the gold standard measure for attachment in young infants is the Strange Situation Procedure3. I think that is probably the most important scientific advance in the twentieth century. However, it takes two or three people about twenty minutes to actually do it, and that is not including the set-up time and the hour and half to rate it. It is not feasible in the NHS. That is one of the reasons we are trying to develop better tools like SAM. We want to develop things that are quick and easy. In terms of intervening with children in schools and families, it is about trying to translate the learning from research into practice. Things like ‘How Nurturing is Our School’ are phenomenally important because teachers who understand the roots of children’s behaviours are going to change the ethos of the classroom. I wouldn’t underestimate the importance of talking about attachment. We have to keep harping on about it. This is not flavour of the month. Attachment is a fundamental instinct that allows children and young people to plug into what they need for their development, and there is a reciprocal caregiving instinct in adults to respond to that. That is the glue that holds our society together.
We welcome responses to the kinds of issues Helen raises in the interview. We plan to edit these responses and put them on the Scottish Attachment in Action website to give us a bigger picture of how we are putting attachment into action.
Following on from this interview, the next recording will be David speaking with our Chair of Trustee's, Edwina Grant.
1. Ruairi, Life Story Collection: Poems after Adoption About Life Before Foster Care. Leicester UK: Ruairi; 2012. A link is available from http://drawingtheidealself.co.uk/drawingtheidealself/Downloads.html
2. DDP stands for Dyadic Developmental Psychotherapy. It is a therapy and parenting approach that uses what we know about attachment and trauma to help children and families with their relationships. Further information is available from http://ddpnetwork.org/uk/
3. The Strange Situation Procedure was developed by Mary Ainsworth and is used to assess the attachment relationships between young children and their caregivers. The child is observed while strangers and caregivers.