Attachment-informed practice with looked after children and young people

This Insight, written by Judy Furnivall, SIRCC, on behalf of Scottish Attachment in Action, examines attachment-informed practice with looked after children and young people. It was completed in partnership with the Looked After Children Strategic Implementation Group.

Key points

• Attachment behaviour ensures the survival of infants and young children by keeping their caregivers close and available to provide protection and comfort. The attachment relationship provides the context for the main developmental tasks of infancy and early childhood, particularly emotional regulation and the development of the capacity to 'mentalise'.
• The characteristics of caregivers affect the organisation and security of children's attachment relationships with them. Sensitive, responsive parenting and parental ability to reflect on the infant's own thoughts and feelings are associated with secure attachments in children.
• Children who have experienced maltreatment are significantly more likely to develop disorganised attachments and these can have lifelong physical, emotional and social consequences.
• Recent evidence from neuroscience confirms the importance of the early emotional and social experience of infants for the healthy development of their brains. Maltreatment can disturb the patterns of cortisol (stress hormone) secretion which can affect immediate and long term mental and physical health.
• Looked after children benefit from developing secure attachments with their caregivers and interventions should support the development of these, whether children remain at home or are cared for outside their family.
• Successful placements are more likely when carers are able to respond to children at their emotional age rather than their chronological one. Interventions with children should aim to address developmental brain impairment by providing care that can build fundamental brain capacities. For looked after children this will mean less use of verbal techniques and a greater concentration on physical, sensory and emotional ways of working.
• Caregivers should be assessed on their capacity to tolerate difficult behaviour and remain sensitive and responsive to the needs of children
• Support and training should be provided to caregivers on a frequent and regular basis to ensure that they are able to maintain their capacity to be reflective about children rather than reactive to their behaviour.
• Attachment-informed practice may require a policy and culture shift to ensure that children's needs are appropriately met when they are cared for away from home.

What is attachment?

John Bowlby first outlined his theory of attachment and its central role in child development more than 50 years ago. Attachment theory is a theory of personality development in the context of close relationships. Why is this process of attachment so important? Although attachment is significant throughout the life span, the special bond that develops between an infant and primary caregiver in the first year of life is usually seen as the template for future relationship experiences. Infants experience this bond as their main source of safety, comfort and pleasure and show intense distress when this relationship is lost, even for a brief period. When children are anxious or distressed they will seek proximity to and comfort from their attachment figures. Children usually build upon their experiences with their caregivers to develop a clear and organised strategy for ensuring that they can achieve such closeness. In evolutionary terms attachment is very important for survival as it ensures that young children remain close to their caregivers, particularly at moments of danger. The quality of children's attachments is strongly influenced by the characteristics of their carers. The more sensitive and reliable the response of a caregiver to an infant or young child in distress, the more secure the attachment will be that develops. It is important to recognise that young children are capable of having different types of attachments to different people and, for example, may have a secure attachment to their grandmother and an anxious attachment to their mother. Indeed many vulnerable children may have developed important attachments to older siblings, neighbours or educational professionals who provided more reliable care than their parents. Over time, children tend to develop an internal working model of relationships based on their experiences of adults. This can be resistant to change even when their emotional and social environment is different.

Children who develop a secure attachment to a primary caregiver have a number of developmental advantages. They are certain of the availability and sensitivity of the caregiver and as a result feel able to explore their environment with confidence and curiosity. Particularly important for children's capacity to understand the minds of others and their own minds (to mentalise) is the parent's ability to tune into and reflect on the infant's own feelings and thoughts. A number of important early developmental tasks involve the regulation of emotion - these include managing stress, controlling impulse and rage, coping with shame and developing empathy. All of these milestones in emotional development are most easily achieved in the context of a secure attachment. If a child has not developed a strong foundation of emotional competence in these areas by the time they enter school, they will struggle to manage the learning and social environment of school as successfully as their peers. Securely attached children also learn an early template for relationships that enables them to make positive relationships as they grow up. Those children with insecure attachment relationships may find all these developmental tasks less easy to achieve and they may experience some interpersonal difficulties in adulthood. It is important to recognise, however, that only about 60% of children experience secure attachments with their primary caregivers and most insecurely attached children are still able to grow up and function effectively as adults. They may, however, find it less easy to become emotionally close to others or alternatively be somewhat clingy with partners or friends and fearful that they will lose any relationships they make. Those children who have been seriously abused or neglected in their earliest years, however, are particularly at risk of developing a disorganised attachment to their caregiver.

Attachment behaviour is activated by stress and children are biologically programmed to approach their caregiver for comfort and protection. Children who experience maltreatment at the hands of their caregivers are faced with an irresolvable dilemma as the person they are dependent upon for safety is the very person who is the source of their distress. Children with this disorganised attachment style represent only about five percent of the overall child population but a much more substantial proportion of the looked after population. Many childhood mental health disorders are associated with this type of attachment and there is evidence that such difficulties may continue into adulthood (Milward et al, 2006; Fonagy et al, 1996).

Attachment relationships continue to be important throughout life and there is some evidence that early attachment difficulties can be reflected in romantic relationships in adulthood and in parenting styles. Although adolescents begin to shift their emotional investment away from their parents and towards their peers, their attachment relationships with parents are still important to them and continue to be so into adulthood. Parents continue to be both a secure base and a safe haven for adolescents and young adults.

'Early developmental experiences with caregivers-the infant's first exposure to humans-create a set of associations and ''templates'' for the child's brain about what humans are. Are humans safe, predictable? Are they a source of sustenance, comfort, and pleasure? Or are they unpredictable and a source of fear, chaos, pain, and loss?'
Perry and Hambrick 2008

'The single most effective way to stop producing people with the propensity to violence is to ensure infants are reared in an environment that fosters their development of empathy. The surest way to achieve this is by supporting parents in developing attunement with their infants.'
The Wave Report 2005

Policy context

Within Scotland almost 16,000 children are 'looked after' by the state. About 40% of these are 'looked after at home' which means they remain within their birth families and receive additional support from social workers. Those who are 'looked after away from home' may live with unrelated foster carers or kinship carers or they may be cared for in one of a range of residential settings. There has been an increased focus on the needs of these children in recent years, partly as a result of evidence that many looked after children have very poor outcomes. They are over represented as adults in the prison population and a substantial proportion of homeless people have a care background. Looked after young people have fewer and poorer attainments in education and are more likely than their peers to have poor attendance or to be excluded from school. In addition, looked after children and young people have more health difficulties than their peers and their emotional and mental welfare is particularly at risk. The Scottish Government report Looked after children and young people: we can and must do better (Scottish Government, 2007) reviewed this evidence and laid out a strategic way forward to address some of these issues. Throughout the report the importance of safety, stability, emotional warmth and attachment for these young people is emphasised. Although there is a general pattern of poor outcomes for looked after children, the report noted that those children who are looked after at home appear to have the poorest educational performance and yet they receive the least support.

Subsequent to this report's publication, the Scottish Government launched the National Residential Child Care Initiative (NRCCI) to undertake a strategic review of residential child care services which reported in 2009. Among the important attachment-focused messages of the NRCCI were that, where appropriate, residential care should be used earlier in a child's care career; that stability of placements should be a high priority; and that residential care should be more connected with the wider child care sector. In addition there was a strong emphasis on accurate assessment using the integrated assessment framework from the Getting it Right for Every Child Programme (GIRFEC) and the importance of well managed transitions. There has been a strong policy focus on the concept of corporate parenting and the Scottish Government published These Are Our Bairns: a guide for community planning partnerships on being a good corporate parent (Scottish Government, 2008) which challenged local authorities to give their looked after children 'the love, security and chances that any good family would provide' (pv). One particular focus of concern has been the experience of care leavers. A report from the Children's Commissioner, Sweet 16? The Age of Leaving Care in Scotland (2008) highlighted that looked after children were often moving into independent living when they were only sixteen years old. This not only represented an enormous financial and social challenge to these young people, it also ruptured the attachment relationships that had provided them with security and comfort while they were in care.

Alongside the increased concern about looked after children is a growing awareness of the life-long impact of adverse experiences in infancy and early childhood. This concern is shared not only by social work and educational professionals but also leading figures in public health, the police force and the business community. The 2005 WAVE Report (Hosking and Ita, 2005) identifies child abuse and failures in attunement and responsive parenting during the earliest years of children's lives as the most important causes of violence in society. The Finance Committee of the Scottish Parliament recently produced a report on preventive spending based on evidence from a range of professionals and agencies across Scotland. This unequivocally recommended the reallocation of significant additional resources for early intervention in children's lives to prevent difficulties, rather than the current focus on reactive intervention at the point of serious harm. The Scottish Government has published an Early Years Framework (2009). This provides an aspirational vision for the provision of services to children and families that could transform the experience of early childhood in Scotland and ultimately bring about improved outcomes for young people and society.

The evidence

Impact of early experience on brain development and physiological regulatory mechanisms

Attachment theory has been developed through careful observation of normal development and identification of the impact on children of suboptimal childhood experiences. These empirical observations have received support from recent developments in neuroscience. There is a growing body of evidence that adverse emotional and social experiences in infancy alter the architecture of the brain itself. Perry and Hambrick (2008) argue that the brain develops in a neurosequential way, starting at the brain stem which governs basic physiological survival behaviours right up to the frontal cortex which is the seat of conscious thought. They suggest that a child's brain develops differently depending on the stimulation provided by the physical, sensory, social and emotional environment in which a child grows up. The patterned rhythmic activities associated with sensitive attuned parenting produce a well-organised functional brain, but for a child exposed to chaotic stimulation or lack of stimulation the outcome is a brain characterised by chaotic dysfunctional organisation or lack of neurological connectedness. Imaging techniques such as PET scans and MRI scans now permit non-invasive examination of the brain. Clinicians and researchers have been able to identify differences between the brains of children and adults exposed to early neglect and abuse and those brought up in a relationally positive environment (Teicher, 2003).

One of the earliest developmental tasks facing infants is to begin to regulate their own stress. Babies are born with little capacity to sooth themselves and are completely dependent upon adults to respond to and manage their stress. Healthy adults respond to distressed babies by trying to comfort them and they use techniques such as holding, stroking, rocking, singing or walking up and down to calm them. The regular, sensitive provision of such comfort, combined with a timely response to physical needs, teaches babies how to deal effectively with physiological arousal without being totally dependent on adults. These are also the caregiver characteristics which promote secure attachment. Babies whose physical needs are dealt with harshly or insensitively or whose distress is responded to with aggression or neglect are left in a state of high arousal and cannot learn how to relax. Failure to create an effective mechanism to control stress has physiological effects and is associated with disturbances in cortisol production. Securely attached infants seem to have a lower reactivity to stress compared to those with a disorganised attachment. (Bernard et al, 2010).

Acute stress triggers a rapid temporary rise in cortisol production which helps to deal with immediate threat, but consistently elevated or depressed levels of cortisol are associated with physical and mental ill health. The normal pattern of cortisol production involves high levels on wakening and a steady decline over the course of the day. Maltreated children tend to have either a consistently high or consistently low level of cortisol throughout the day. Studies in adult survivors suggest that these disturbances in cortisol production can continue into adulthood. (Pierrehumbert et al, 2009).

Preventive and therapeutic work with families and children in the community

The biological evidence provides a strong argument for the importance of improving attachment security and organisation for infants in order to prevent physical and mental health problems throughout the life course. There is also a link between attachment experiences and later social difficulties. Recent evidence suggests that secure attachment in infancy may help toddlers to manage the inevitable assertion of parental power that accompanies the socialisation process of young children. Conversely, insecurely attached children are more likely to embark on a mutually adversarial pathway in which children's resentful opposition to parental demands evokes increased coercion from parents and ultimately an increase in antisocial behaviour and aggression from children (Kochanska et al, 2009).

Many children who are looked after at home continue to experience stress and difficulties in their families, with adverse consequences for their emotional development, behaviour and attainment. Parents may be struggling with their own unresolved childhood experiences or be overwhelmed by stress in their current lives engendered by domestic violence, living in an unsafe community or through their own mental health problems. These difficulties are likely to interfere with their capacity to provide attuned parenting. Children and adults may become trapped in a mutually reinforcing cycle which exacerbates difficulties and leaves children distressed and resentful and adults overwhelmed and deskilled. Attachment promoting interventions such as Mellow Babies (Puckering et al, 2010) or the Solihull approach focus on increasing the use of behaviours such as attunement, relief of distress and reciprocity between baby and caregiver. These seem to be particularly effective in improving parent child relationships.

There is also some evidence that suggests that stress in pregnancy increases the infant's reactivity to stress. A new programme, Mellow Bumps, is being piloted with the aim to reduce maternal stress and increase pregnant women's awareness of the emotional needs of their babies. The Circle of Security project works with high risk pre-school children and their caregivers using an attachment based intervention that helps adults to understand the concepts of a secure base for exploration and a safe haven at times of distress (Marvin et al, 2002). Through the use of video clips the caregivers are encouraged to try and understand what their child is feeling and thinking - this promotes reflective attunement and dialogue. The results of the intervention showed a significant number of children in the project moved from disorganised to organised attachment and that several became securely attached to their caregivers. In both the Circle of Security and Mellow Babies interventions, caregivers were also given support with their own distress and adverse past experiences. This seemed to help them to achieve a measure of resolution for their own problems and enabled them to become more psychologically available to their children and accepting of their needs.

Intervening in the early years is cost effective and can lead to a rapid improvement in the quality of life for children and their caregivers but there is also evidence that children can be helped through attachment promoting interventions later in their childhood. The Connect programme (Moretti et al, 2009) focuses on developing parental sensitivity, the shared regulation of emotion and the capacity for reflection with teenagers at risk of aggressive behaviour and their parents. This programme reported positive changes in the behaviour and emotional functioning of the teenagers as well as increased satisfaction and competence in the parenting task. For many looked after children their parents' substance misuse can be key to the failures in attachment and consequent impairments of children's development. Attachment based work in a residential treatment centre for drug-using mothers led to an increase in reflective functioning, maternal sensitivity and improved mother child bonding. This was accomplished through providing a rich alternative relational experience for the mothers in the therapeutic milieu and enabling them to recount their experiences of being parented as well as to explore their own parenting behaviours and aspirations (Wong, 2009).

Children in out of home care

Many children who are looked after experience their first episode of out of home care at a very young age as a result of abuse or neglect. These children are often returned to their parents even though no significant improvement has taken place in the family's functioning and they may experience further maltreatment. Zeanah and colleagues in New Orleans have taken a rigorous approach to assessing and intervening in the families of maltreated young children who have been placed in foster care (Zeanah et al, 2001). They identify barriers to the development of positive attachments and work with families to remove these within an appropriate developmental time span. If families are unable to achieve the necessary level of change then the placement with the foster carer becomes a permanent adoptive placement. This approach seems to have a number of positive outcomes. When children are returned to their families there is a significant reduction in further episodes of abuse, both for that child and subsequent siblings. Even where a child is not returned to their parents there is a positive impact on siblings remaining at home. For those children who are permanently removed from their parents the work done with the foster carers to ensure appropriate matching and to promote attachment means a reduction in the number of placements a child experiences. A version of this approach, modified to suit the Scottish context, is about to be piloted in Glasgow.

There is a substantial body of research that focuses on the experience of foster and adoptive carers looking after small children with a history of maltreatment. Although some young infants will be able to respond quickly to the change of emotional environment and form secure attachments to their carers, not all children will respond so positively. Dozier's work suggests that some maltreated children are mistrustful of adults and resistant to support. They do not seek care or comfort even when distressed. If carers wait for the child's signal to provide care in such cases the child's needs remain unmet. Foster carers trained in a programme called Attachment and Biobehavioural Catch-up (ABC) were able to offer additional nurturing and provide care even when it was not sought by these children. The impact of the intervention was not only at the relationship level; it also succeeded in reversing abnormal stress hormone responses by developing a normal daily pattern of cortisol secretion in the children (Dozier et al, 2006). The programme focused on caregivers helping children to develop their regulatory capacities, enabling carers to reinterpret the behaviours that children used to alienate them, and supporting them to deal with their own emotional issues that interfered with providing nurturing care to the children.

Dyadic Developmental Psychotherapy is an attachment-focused approach in which a therapist supports the caregiver and child's relationship and the development of secure attachment by encouraging the reflective function of the caregiver, enabling attunement, regulating emotion and co creating meaning. The therapist interactions are characterised by PACE (playfulness, acceptance, curiosity and empathy) and similar qualities are supported in the caregiver with the addition of love (PLACE). This approach has been well evaluated with foster carers and adoptive parents and recently elements of this model have been successfully introduced within residential child care (Becker-Weidman and Hughes, 2008).

There is clear evidence that children who are looked after away from home are particularly vulnerable to emotional and mental health difficulties and this morbidity is greater in older children (Milward et al, 2006). Helping children to develop secure attachments to their carers is not sufficient by itself to address these problems. There is, for example, evidence that children who meet the diagnostic criteria for Reactive Attachment Disorder, which is associated with early maltreatment, may have developed a secure attachment with a current carer. It seems likely that part of the importance of a secure attachment for looked after children is that it provides the medium by which future developmental tasks may be achieved. Successful programmes in both residential and foster care are those able to devise appropriate ways to respond to the emotional age of the child rather than to their chronological age. Perry and Hambrick (2008) argue that it is important to link interventions to the impairments in the brain. So for example a child who has difficulties regulating stress would need an experience similar to that of a baby who is cradled and rocked by a sensitive mother. Although foster or residential carers might feel comfortable providing this to a young child, it would be inappropriate when caring for a teenager. The use of other strategies that can help regulate stress such as massage, yoga, music, sensory integration and relaxation can, however, be appropriately be used by adults caring for children of all ages. Seamab School, for example, has developed a carefully managed programme of massage which has enabled children to recognise and seek help in regulating their own hyperarousal. This has reduced the number of violent incidents and the requirement for physical restraint. In many of the settings in which looked after children are cared for, however, the focus of concern and intervention is at the behavioural and cognitive level. According to Perry's model this is likely to be ineffective as it requires children to have a properly functioning frontal cortex and their life experiences will have prevented such development.

Some residential settings have begun to reframe their interventions using a specific focus on attachment and recovery from trauma. Cameron and Maginn (2008) have developed the concept of the pillars of parenting which emphasises the importance of authentic warmth between adults and children in residential child care. They describe seven essential dimensions of parenting which include secure attachment, emotional competence and self management. This model emphasises the crucial role of the direct carers in healing severely hurt children through attuning to their needs, despite being exposed to extremely challenging and rejecting behaviour. Edinburgh City Council has adopted an explicitly attachment promoting model of residential child care based on work in Canada and this focuses on the need to understand the meaning of behaviour and to develop self regulatory skills in the context of positive safe relationships (Moore et al,1998). These approaches share a focus on the relationship between carers and children as the basic tool in creating healthy change and good outcomes. The difficulty for adults in developing and maintaining a positive connection to children who are hostile, withdrawn or resistant is also recognised, and external support is provided to carers to ensure that they are able to remain psychologically available to children and not withdraw into a distant and punitive stance.

Carers and workers

A consistent theme throughout the evidence of effective intervention with children looked after away from home is the central importance of the adult caregiver's capacity to reflect on the child's behaviour in order to help them understand the child's thoughts, feelings and needs. This is exactly what normal parents do when confronted by a crying baby. Most parents can recognise that this apparently simple caring task can become overwhelming and frightening if children refuse to be comforted, despite every attempt to identify and respond to their needs. Support from partners, extended family or friends can be crucial to survive such moments of crisis. Caring for children who have disorganised or extremely anxious attachments can provoke similar emotional upheaval in carers. Research undertaken by the University of Bristol for the Department of Health found that only seven percent of the foster carers in their study had experienced no stressful life events in the previous six months. Over half had experienced between one and three such events and nine percent had experienced seven or more stressful life events during that time. Stress is inherent in the fostering task but this level of stress clearly had an impact on the success of placements. The main factor alleviating stress for the foster carers was support from others in their professional or social networks. Where there was timely and effective support from social workers this was particularly important. Where social workers were difficult to contact or minimised the concerns of foster carers this exacerbated the strain on carers. Strain had a direct impact on the parenting capacities of carers and in particular inhibited their ability to respond to children at their developmental rather than their chronological age. Moreover carers were more likely to dislike the children placed with them and have a reduced commitment to them if they were experiencing severe stress (Farmer et al, 2005).

Wilson (2007), after analysing data from a large study on fostering outcomes, suggests that the very difficult behaviours presented by some children can activate self defence mechanisms in caregivers which interfere with their capacity to provide sensitive parenting. The interaction between children's difficulties, carers' parenting capacities and levels of support and stress is complicated and can change within and between placements. What seems clear, however, is that the inherent difficulty of the child's behaviour is by no means the only factor affecting placement outcome. There is some evidence that the attachment security of foster carers or adoptive parents affects the outcomes for the children placed with them (Dozier et al, 2001; Steele, 2006) although this has not been replicated in other studies (Caltabiano, 2007). It has also long been recognised that the residential child care task is an emotionally demanding one and that residential workers need to be 'at core, independent enough to withstand the battering of children who are at the least adrift, and who may be very damaged and bewildered' (Beedell and Clough, 1992). Recruitment strategies for residential child care, however, rarely require the same kind of intensive personal reflection and examination that are normal practice in assessing foster carers. The quality of support to adults caring for looked after children seems to affect sensitivity of 'parenting' and stability of placement (McCollam and Woodhouse, 2006).

Assessment

Although there are a few validated tools, such as the Strange Situation procedure, for assessing the type of attachment strategy that a young child uses in relation to a particular individual, these take considerable time to administer and code. A recent systematic review concluded that there are no quick or easy measures of attachment available for young children (Lim et al, 2010). There are, however, numerous examples of tools that can measure family functioning on a wide range of dimensions (Pritchett, 2010). For young children who are placed away from home it may be more important to assess the functioning of the family in which they are to be placed, and the capacities of the adults to provide responsive attuned care to the specific child, than to assess attachment security and organisation. There appears to be consistent evidence that for older children it is important that their caregivers can respond to them at their developmental age rather than their chronological age. Tools such as the Behavior Rating Inventory of Executive Function (BRIEF) can identify deficits in executive functions. Executive function emerges in the preschool years and strengthens throughout childhood and adolescence. It integrates a number of skills such as the ability to control impulses, manage frustration, remember things, and show mental flexibility to enable an individual to achieve goals through planning and organisation. Although the BRIEF does not assess developmental age directly, it can help to guide appropriate developmental responses. There is a general recognition among foster carers and residential child care workers that the young people they care for behave like much younger children. There is less awareness that the developmental stage they might be seeing is actually that of an infant or toddler. The use of the integrated assessment framework which is part of the GIRFEC practice model may be helpful in more accurate assessment of young people's developmental needs.

'The findings of our research make it clear that strain on foster carers reduces their capacity to parent well and has an adverse effect on placement outcomes, both in terms of disruption and the quality of the placement for the young people.'

Farmer et al 2005

Practice implications

Children looked after at home

If children require compulsory supervision while living at home, then they and their families deserve a timely and focused intervention that can support the development of secure attachments. Simply monitoring families cannot promote change and may undermine existing positive parenting strategies as parents become deskilled through fear of being judged. For infants and very young children, early intervention can be very effective, particularly where parents' own emotional and practical needs are also given attention. Patterns of relating may be more entrenched for older children and adolescents but an attachment-focused model can still promote change. Regardless of the age of the child, the key components of such interventions should include increasing the sensitivity, responsiveness and reliability of parents and their capacity to think about the feelings and thoughts of their children rather than just their behaviour. It is also important to focus on helping parents support the child in developing skills in self regulation. Helping parents and children to develop reciprocity through shared play or enjoyable activities can enable a mutually satisfying relationship to emerge. This type of intervention, however, can only work if the parents are not a source of danger to the child and are not prevented from improving their sensitivity and responsiveness because of addiction or mental health difficulties. Accurate assessment of parents' capabilities in this area must be undertaken and where necessary early decisions about removal and permanence should not be avoided. Neglected and abused children may be successful in getting some of their attachment needs met by other people in their immediate network; indeed for some children the family pet may have been one of the few sources of responsive, reliable and consistent warmth and affection. Any assessment of a child should identify possible alternative attachment figures and good planning should include maintaining and supporting such relationships even in the event of a child being removed. In some cases this can lead to the identification of potential kinship care arrangements that will meet the safety needs of children without disrupting valuable attachment relationships. If children have to be separated as a result of an admission to care it is important to recognise that older children are often attachment figures for their younger siblings and that in such cases both children will experience acute anxiety at being placed apart from each other. Ensuring that there is regular, reliable and meaningful contact between siblings is essential.

Children in alternative family care

For many children placement in an alternative family provides the best chance for developing a secure attachment and emotional and psychological recovery from trauma. Foster and adoptive carers already undergo extensive assessment procedures but it is important that this assessment takes account of carers' capacity to tolerate challenges and ability to understand the meaning of difficult behaviour. Carers who have experienced adversity in their own past can provide extremely empathic and sensitive care but it is important that they have achieved a measure of resolution of their own difficulties. Many children placed in alternative families will present extremely difficult behaviour but every child will have a unique set of needs and strengths. If a child is placed with other children it is important that the impact their arrival will have on the family unit is assessed. It can be difficult to provide sensitive attuned care if there are too many children in a family or if the needs of children conflict. Carers need both training and support to provide the environment in which children can begin to recover from failed attachments. The primary task of carers is to create physical and emotional safety for children (stability and security), and then to help them to reduce anxiety through co-regulation. Policies should support foster carers to respond to the emotional age of the child, which may mean providing a great deal of basic physical nurture as well as emotional responsiveness. Social workers should support carers to work out the most appropriate way to parent the child, taking into account their history and developmental stage. There should be a specific focus on using the relationship between child and carer to address the developmental deficits and likely neurological impairments experienced by the child. This may involve concentrating initially on touch, sensory stimulation, music and play, as well as providing a safe, predictable routine and environment for the child. This will lead to the carer being able to support the child in learning about emotions and developing the capacity to mentalise. At this point the child may begin to experience success in peer relationships and learning.

Children in residential care

Providing the context for the development of secure attachments in residential care is a more severe challenge than in foster care because there is instability built into the relational environment. For some children and young people, however, foster care is not an option because of the severity of the challenge they present. Others prefer residential care, either because of a loyalty to their own families or because of suspicion and anxiety about intimate relationships. In some cases residential care may also be the best way to keep siblings together. Often the children in residential care have had extremely damaging experiences in their families and present very challenging behaviour. They are likely to have similar developmental deficits as those in foster care, and will need similar interventions. and it is important that such experiences are created for them. One advantage of the residential child care setting is that there is a choice of different adults for children to connect with and this makes it more likely that a child will be able to find an appropriate match. There can, however, be organisational and policy constraints that interfere with the development of positive attachment relationships in residential care. Shift patterns, training, holidays and sickness all disrupt contacts between children and carers. In addition 'special' relationships between children and particular members of staff are often viewed with suspicion. 'Treating children the same' and 'fairness' are often elevated above responding to individual need.

Providing attachment-informed care in residential settings requires a policy and culture shift which recognises and values the healing potential of special relationships. Some children's homes already do this and in these settings the inevitable disruptions in relationship that happen are recognised as painful and anxiety-provoking for children. The experience is planned for and the staff member is talked about with the young person while they are away. Staff members are encouraged to demonstrate to children that they are holding them in mind, perhaps by leaving a token gift for the child, or writing a postcard when they are away. Safe touch is encouraged and workers feel comfortable in undertaking primary care tasks such as washing a child's hair. It is obviously essential that such interactions are transparent and planned rather than covert. Predictability and routine are important factors in creating a sense of safety but consistency is not always easy to achieve in residential settings. For children with impaired attachment it can be helpful to have a detailed twenty-four hour plan which is developed in response to their individual needs. A residential child care setting is a complex environment and its daily management absorbs a great deal of emotional and intellectual energy. Children, however, require adults who strive to understand their feelings and thoughts rather than just react to their behaviours. Developing a reflective and responsive culture among both staff and residents is an essential component of attachment-informed care.

Supporting adults

Residential workers and foster carers expose themselves to potentially toxic experiences when they attempt to engage at depth with seriously hurt children. Vicarious trauma or burnout are real risks for these adults. It is important that the emotional energy which is expended by adults caring for children who are looked after away from home is matched by an equivalent level of support from managers, link workers, trainers and external consultants. Such support should not be crisis driven. Regular reflective space and non- judgemental listening can promote sensitive, responsive care and alleviate strain. The containing relationship derived from regular supportive contact can also provide an effective source of help at moments of crisis. Management structures and policies that support attachment-promoting care rather than defensive practice are essential. Training that enhances understanding of the impact of adverse experiences on development and behaviour should be available for all staff and carers on a regular basis. Basic training about attachment and trauma should also be available to other professionals who come into contact with looked after children. This can help them understand difficulties that children present outside their home and this understanding can reduce stress on placements.

Managing transitions

Understanding the importance of attachment can inform the planning and management of transitions for children and adults. Every time a child moves from one living situation to another it involves separation from a caregiver and the likely disruption of an attachment. Changing teachers or schools can also disrupt relationships that have particular meaning for children. Insufficient thought and respect is usually given to the meaning and importance of relationships when change is planned. Children need to create a coherent autobiography for themselves to develop their identity and sense of self. If they experience a series of placements with little or no connection between them this is hard to achieve. Whenever possible children should remain in the same placement unless there are strong reasons to move them. When a move is inevitable special relationships should be recognised and supported for as long as they remain important to the child. It is important to recognise the impact on staff, carers and other children of a child moving placement, whether this is in a planned way or as a result of disruption. Immediate placement of another child in the same foster home or residential unit should be avoided where possible. All transitions, including those of staff leaving a home, should be marked and, where appropriate, they should be celebrated. The particular importance of the transition from residential care into independent living cannot be over estimated and policies should support the continuation of relationships between young people and those who have been caring for them. They, and the environment they live or work in, should continue to be a secure base and safe haven for those young people who have left their care.

'The experience of a prolonged insecure attachment, whatever the cause, has long been suspected of producing 'invisible damage'. New methods of measurement in neuropsychology and neurobiology have been able to quantify this damage in terms of brain growth and activity. In short, we now know that parental rejection, abuse and neglect not only cause grievous developmental harm, but also grievous bodily harm.'

Cameron and Maginn 2008

References

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