All social workers in the care system should be trained in recognising and assessing attachment, according to proposed guidelines.

The draft guidelines by the National Institute for Health and Care Excellence (NICE) argues that health and social care providers should train all key workers in assessing attachment difficulties and parenting quality, for children in – or on the edge of – care. I couldn't agree more and I'm a little disappointed that this isn't already the case. This post, covering the origins of attachment theory, will be the first in a short series on attachment and it's implications for social work practice. 

Attachment theory is almost 75 years old. During this time, some elements have changed but the underlying principles remain as true now as then. In the 1940s and 50s John Bowlby worked with children who had been either separated from their parents as war orphans or evacuees or who had experienced significant adversity in their early life. He believed that these children went on to experience a range of emotional, behavioural and psychological difficulties as a result of their early experiences of loss and trauma.

Bowlby has been criticised for developing a normative theory of development based on non-normative experiences. He was trained in a psychoanalytic tradition, but was disillusioned by its intrapersonal focus; instead he was influenced by the important empirical discoveries happening around the same time. I’ll outline some of them below:

In his 1943 book, The Nature of Explanation, Kenneth Craik described the central nervous system as “a calculating machine capable of modelling or paralleling external events” and saw this as a basic feature of thought. He described the human or animal in this way:

This might seem obvious to us now but to John Bowlby it provided a pragmatic explanation to the adverse developmental outcomes he had seen in orphans and institutionalised children; more so than the psychoanalytic training of his background because Craik’s theory was outward looking; seeing the individual in context.

John Piaget described intellectual development as a process of adjustment and adaptation to the world. As part of this growth children have to go through a process of assimilation and accommodation. Assimilation involves the inclusion of new information into existing schema or internal working models. Accommodation happens when a child is not able to assimilate information into an existing schema and either has to change the schema or develop a new one.

Craik and Piaget were important for attachment theory because they explained how infants develop schemas or maps for future relationships based on prior experiences and learning. 

Niko Tinbergen and Konrad Lorenz were ethologists studying the sociology of birds. Their careers travelled in parallel, influencing each other along the way. Lorenz was inspired to conduct a study involving goslings which ultimately led to the imprinting hypothesis. In this study Lorenz split a large hatch of goslings, leaving half with the mother and taking the other half and raising them himself. Over the course of their development the goslings quickly identified him as their primary attachment figure and followed him, copying his behaviour. He taught them to swim, he used to call them with a special horn for feeding time and they always followed him. When they were given the opportunity to return to their birth mother, they didn’t recognise her as such, instead preferring Lorenz. This taught us about the importance and probable biological nature of the bond between mother* and offspring, in which the mother, the primary attachment figure, is the one who provides physical and emotional care and nurture.

As a light break, you might enjoy the following Tom & Jerry cartoon where they, in a very flippant and simplified manner, explain the concept of imprinting.

Later, in the 1960s Harry Harlow carried out a series of lab based experiments on monkeys (seen at the top of this post), rearing them in total social isolation. The study, which was unquestionably cruel, showed that monkeys were preferentially seeking out a cloth mother for nurturing; spending up to 18 hours a day holding onto her and seeking out a wire mother only for food. All the means for a healthy development were available and yet the monkey showed severe damage as a result of their experiences. The study suggested that mammals need reciprocal nurturing and attachment as much as they need their physical needs met. 

Bowlby hypothesised that since humans cannot survive without adult care our evolutionary history has selected pre-wired dispositions on both the part of the adult and the child that ensure human survival. From this basis, Bowlby developed a model of attachment that is monotropic (has a single attachment figure). 

The regulation of emotion and behaviour are tasks that the care giver and child accomplish together through reliable, responsive and consistent care giving. The care giver provides the infant with the necessary up-regulation and down-regulation that the infant needs. Consequently, parents that are not attuned to the infants needs, and cannot reliably and consistently provide care, leave the child without the necessary external regulatory support. Over time this develops into a complex system which affects the way in which a child, and eventually adult, responds to their own needs and to those other others. 

I hope you've found this post interesting. You might also be interested in my post on Attachment Based Family Therapy. I'll write more on the current debates in attachment and methods of assessment soon. Follow me on facebook and twitter so you don't miss them. 

Originally researchers and practitioners imagined that resilience was born out of some temperamental factor, innate to a person and not amenable to change or intervention. Temperament was one of those factors but there are other important factors including education, cognitive ability, social support and economic resources.

In the second wave of resilience research theories of psychology started to come to the fore. Researchers incorporated theories of developmental psychology, considering the effects of timing in interaction between the different developmental variables. This allowed for a more subtle understanding of resilience in which trajectories were not foretold but could be influenced by the addition or subtraction of key variables.

In the third wave, resilience research started to focus on intervention to improve outcomes. This is a challenging area to study as resilience interventions can have distil outcomes in a range of different domains, not all of which are predictable. For instance, an intervention focused on education improvement might lead to a child one or two generations down the line not growing up in poverty.

In the fourth and current wave of research, existing findings have been reconsidered in the context of new data on genetics and neurobiology. This information provides us with new way to describe and analyse existing data rather than providing causal explanations per se. 

One example of how gene/environment interaction research is influencing our understanding of risk and resilience is the theory of differential susceptibility put forward by Jay Belsky and Michael Pluess. They noted, as has also been seen in clinical and research practice, that children experiencing the same risks and the same environmental stresses were having differential outcomes. They queried whether the diathesis-stress model could adequately explain these variations.

Pre-natal and genetic risks are individual factors included on the Y axis whilst stresses or environmental influences are captured on the X axis. This is a classic model and has helped to inform many theories in clinical psychology. It also underpins political agendas around resourcing interventions in the early years of a child’s life. It is however, in its simplest format here, problematic. It gives the impression that stresses affect an individual in accumulative fashion, ignoring the effects of timing and development, the nature of stresses or concurrent resilience factors. The model focusses on many negative outcomes ignoring the moderating effect of positive influences.

Belsky and Pluess noted that what was additionally missing from this model was a recognition of the role of individual plasticity. Plasticity is a term used to describe the ability of the brain and its bio-behavioural network to respond to new information. Infants have high plasticity in order to accommodate new learning and develop rapidly. As we get older plasticity diminishes. An example of this is the capacity of a five year old versus a fifty-five year old to learn a new language. For the five year old this is an easy task with learning happening almost unconsciously. For the fifty-five year old acquisition of a new language will be possible but challenging, even with very deliberate learning.

When we include the concept of plasticity in our understanding of risk and resilience we make some interesting new discoveries. It also teaches us the importance of thinking about positive and negative influences and outcomes together. So, if we imagine a child who has experienced some significant adversity and yet appears to be coping we describe them as resilient and, indeed, they don’t suffer a catastrophic fall in the face of their difficulties but instead manage to maintain a reasonably even keel, perhaps even managing to make some slow progress along normative developmental lines. This child’s ability to resist the worst effects of the negative environment protects them; however, it also means that they don’t get the full benefit of a positive environment.

In contrast, some children don’t fare so well. In the face of adversity they have catastrophic outcomes. These children are called non-resilient. However, an important detail is being missed here. These children are showing plasticity in their development. In the face of a negative environment their outcomes are poor so they’re susceptible to the influences around them. What this also means is that if we give these children a positive environment with good resources they have to potential for a favourable outcome. So, what puts them at risk of an adverse outcome also gives them the opportunity of an incredibly positive outcome, and they may actually achieve more than those children who we’ve traditionally labelled as resilient.

Adoption is widely regarded as an effective intervention for children who’ve been born into families where there are significant risks associated with abuse, neglect, domestic violence, substance use or other multiple risks that prevent 'good enough' parenting. For children where there is the prospect of repatriation back into the family through improvements in parenting, fostering or institutional care can provide a good compromise position. However, children who have been fostered or are institutionalised tend to show high insecurity and attachments and general delays in development, suggesting this is not the best final solution. In that respect, adoption provides a much better option. Nonetheless we know that adopted children can have problems afterwards: they make slower progress at school; have more behavioural problems during middle childhood; and are more likely to be referred to child and adolescent mental health services.

In light of this IJzendoorn and colleagues conducted a meta-analysis, including 230,000 children who had been adopted or remained with their birth families, fostered or institutionalised to examine outcomes in height, weight, IQ, self-esteem, internalising problems; externalising behavioural problems; and attachment security. 

What they found was what they describes as massive catch-up, particularly noticeable in height and weight but also IQ. Self-esteem showed no difference to children brought up in their birth families. Externalising problems were slightly more prevalent. Attachment security was lower than that for birth children at 47% compared to 60-70% in birth family children. But that is still twice as high as children who had been fostered or institutionalised. They concluded that adoption is a highly effective intervention building resilience and mitigating against the risks of an early challenging childhood 'if no other solutions are available'. Of note, this mata-analysis just looked at adoption as an intervention and because it covers a lot of studies we can cancel out the effects of more specialist or therapeutic interventions. Therefore, what we can see is that adoption has dramatic outcomes for children, reducing risk and increasing resilience.

Last week I started a 6 week course with the University of Edinburgh called The Clinical Psychology of Children and Young People. Child psychology is an area that particularly interests me and I'll post some of my own interpretations of how the material can be used in social work practice. I have studied it extensively in the past; however, I believe that as Social Workers we should continually refresh and build upon the knowledge that forms a basis for our practice. Like renewing a first aid certificate. I hope you find these posts interesting and helpful.

This week we looked a child and adolescent development, factors that influence development, and models of developmental psychopathology. An understanding of children’s development helps us to interpret children’s well-being and mental health, and taking a developmental approach is important as it helps us to spot and interpret a number of different patterns and behaviours. Furthermore, looking at developmental outcomes (milestones) allows us to see when development is atypical and helps us to identify ways in which the child may need supporting.  

Children are qualitatively different from adults, they are not born as mini adults, and they are not born as empty vessels. They are complex in their development: some development occurs slowly and over time; other times development occurs rapidly such as in infancy and adolescence. To help, we can break it down into the following phases of development:

1. Development happens between conception and birth
2. Infancy, between birth and two years, is a time of rapid growth in every aspect of development. By two and a half children are usually half their adult height. 
   
3. Early, middle and late childhood, between the ages of three and ten years, is a time of refinement of motor skills and huge cognitive changes. 
4. Early, middle and late adolescence, between the ages of eleven and twenty, is a period when children moving away from the family and into independent adulthood.  

There are also different aspects of development:

1. Physical development – Motor coordination, fine motor coordination, growth in height and brain development. Physical development can be quite easily observable but not necessarily. 
2. Social and emotional development – friendships children make, relationships they have with their parents and peers, how they feel about the social world they're in, and how they manage their emotions
   
3. Cognitive development (Cognition) – Thought processes, such as memory, reasoning, and attention. Much of it is unobservable and it can be difficult to detect. 
   

Of course, the child develops as a whole and the different aspects of development do not occur in isolation. They all interact with one another. To understand this we look at patterns of development.

Development isn't always progressive. There are various patterns of continuous change. Sometimes development can be very rapid and sometimes change is slow and gradual.

At 18 months children start to engage in pretend play. Pretend play starts to decline during middle childhood as other forms of play become more prominent. This pattern of continuous development is often known as an inverted U function; where you can see that development increases and then declines.

You can also have U shaped continuous change where you see an apparent decline that actually leads to an improvement in development. Often this is true of cognitive development where a child’s behaviour may look like it is becoming more difficult but actually, cognitively, they are re-evaluating how to perform the task and then their performance improves.

Another pattern of development is stage changes. This is where you have changes in ability which seem to take quite a dramatic shift. A classic theory of stage changes is Piaget’s theory of development. He outlined four stages of cognitive development:

1. Sensory motor stage between birth and two years. 
   
2. Pre-operational stage between three and seven years.
   
3. Concrete operations between seven and eleven years.
   
4. Formal operational between eleven and fifteen years.
   

Piaget argued that each of these stages is typified by a new range of cognitive abilities or operations that allow children to cognitively perform at a different level.

There are many influences on development. Firstly, biological influences like genetics and the brain.

Genetics have a probabilistic relationship with development. They do not always determine or cause different developmental outcomes but they influence it through interacting with other genes and other things in  our environments. An example of where genetics do have a direct link with development is in Down Syndrome. It’s a chromosomal abnormality that lead to a particular set of features and characteristics. Most genetic contributions are, however, probabilistic and they are seen as a risk or protective factors rather than direct causes.

Twin research studies have been helpful in assessing the relative role of genes versus environment. As a result some mental health conditions and difficulties have been found to have a genetic component to them. For example, schizophrenia, ADHD, Autism, developmental dyslexia. However, genes aren't the whole story they are just a part of it.

The Human Genome Project has helped to identify which genes or constellation of genes influence particular developmental and mental health outcomes. For example, we now know particular genes are involved with autism. We also know that some genes and combinations of genes act as protective factors as well.

Brain development is also a significant biological influence. We know that there are important growth spurts which occur in the brain, firstly in infancy, and then later in adolescence. In the first two years of life we know that the brain grows enormously; but even more important are all the connections that are made in the brain that are related to the experiences the child has both physically, socially and emotionally. The more experiences a child has the more connections are maintained. If those experiences don’t occur or are reduced then the synaptic connections are pruned. This means that early brain development in infancy is very much a product of the environment the child is in; but in turn that brain development itself offers developmental opportunities for the child. 

The next major changes in brain development occur in adolescence which coincide with puberty. I’ll write a separate post on this later.

Biological influences are really important but the environments within which children live and the people they live with are crucial to their development. We refer to these as social and environmental factors. Not only do the people a child lives with influence the food they eat (whether they have enough), the house and community they live in but also the people around them give them opportunities to learn and improve their understanding of the world and themselves. Also the people around them help them to form relationships and emotional bonds with others which can last in the long term.

Social workers can use a tool (based on Bronfenbrenner’s Ecological systems theory) to assess a child’s social and environmental factors. A child can complete a task with concentric circles with them in the middle; identifying who they think are important to them. Most importantly you should ask the child why they feel they are important.

Developmental psychopathology focuses on normal and abnormal development and also adaptive and maladaptive processes. It shows us that there are a range of developmental trajectories that a child can take.

Compas and colleagues undertook a review of adolescent development and highlighted that there isn’t just one developmental pathway or trajectory. They identified five:

1. Stable adaption - A young person shows few problems
   
2. Stable maladaption - A young person shows continual difficulties through a childhood and into adolescence.
   
3. Adolescent decline - A young person may not have previously been experiencing difficulties and then in adolescence difficulties began. 
   
4. Adolecent turnaround - A young person may have been experiencing problems as a child and then in adolescence something happens to lead them on a more adaptive pathway. 
   
5. Adolecent limited maladaption - A young person in mid adolescence can begin to have difficulties psychologically that are resolved before then end of adolescence. 
   

This model is important as it highlights that adolescent development doesn’t just have one pathway. There are a range of different pathways that young people can find themselves on depending on a range of different factors and influences.  

Social Workers work with children and use skills based upon child development in their everyday practice. We observe children and learn something about how they’re developing and their well-being from our observations of them. We speak to children and learn about their development directly from them. We sometimes use little tasks and drawings and even short questionnaires and scales. If you'd like to find examples of scales and questionnaires that might be helpful in your practice please take a look at the tools section of this website. 

Next week I'll be covering the topic of resilience. Please follow me on facebook or twitter so you don't miss it!