Children’s Court of NSW Resource Handbook — Care and protection — articles

An attachment relationship is the fruit of early childhood development, meaning that a child has been well cared-for, and a consistent caregiver, or a few consistent caregivers, have effectively responded to his or her needs. In well functioning families, the baby decrees what should be done and the caregiver learns to interpret and meet these needs. A “good enough” mother is sensitive and flexible in the way she studies and reacts to her baby, and intuitively learns how to supply what is required.

In this safe, predictable environment the primary caregiver can become a “secure base” for the child. The child knows the mother is there to provide security when it is required, so that he or she can then safely learn about the world through personal exploration. A baby brought up in this secure, nurturing environment learns to expect relationships to be reciprocal and direct. A signal from one person leads to a straightforward response from the other.

From this start, these children are more likely to learn that the world behaves according to intelligible principles, they will expect rewarding relationships based on assertiveness and empathy, they are comfortable with bodily contact, and will be predisposed to enjoy school and other learning activities.

For a human baby, born the most vulnerable of species, it is highly dangerous to be unattended, or not responded to appropriately. Babies are built, both biologically and psychologically, to engage with, and elicit care from others. The caregivers who make them most comfortable are those who are stronger, wiser, safer and irrationally interested in their welfare. Naturally, a primary, predictable caregiver, usually in the form of a mother, often manages to fulfil these demanding occupational criteria.

Home should be the safest of places, yet we know that for some people home is the place of greatest danger. How do people manage to survive in some homes? When the mother does not respond to the baby’s cues (eg eye contact, crying, physical movements), the baby has to adapt differently. Infants need to adapt to dangerous family experiences by using the “anxious” strategies of “defended” (usually seen as a “Type A insecure” or “avoidant” strategy) or “coercive” (or “Type C insecure” or “ambivalent”) attachments. Crittenden (2008) regards these anxious attachment strategies as inherently adaptive, in that they protect the infant, and help unresponsive caregivers to be forced to meet these needs.

Early development from the abused child’s perspective:^[11]

In other words, child abuse and neglect can affect every area of a child’s health, development and potential. The challenge for Children’s Court Clinic clinicians is to understand what are the needs and resources, and the developmental risks and strengths, for each particular child.

Children who are neglected may be delayed in all areas, but it is common for them to have normal gross motor milestones, and delayed language and social development.

Human development is not individual, but social. Bronfenbrenner’s social-ecological model of development (1979) describes these influences as intercultural, community, organisational, and interpersonal or individual. He saw the individual, organisation, community, and culture to be nested factors, like Russian dolls. Each echelon operates fully within the next larger sphere.

Figure 1. FIGURE 1: A simplified version of Bronfenbrenner’s social-ecological model of development.^[13]

Risks to children tend to be cumulative, but attachment is the central focus. Peter Fonagy (1998) reviewed relevant developmental factors in relation to a vulnerable population of infants. He categorised risk and protective factors within early development, as linked to social inequalities:

He concluded that the relationship with the caregiver is arguably the most important mediator of the impact of social inequalities on early child development. This view is strongly supported by Schore’s (2003) review of more recent research, which concluded that social stressors related to attachment or “relational” trauma, whether abuse or neglect, can lead to severe affect dysregulation and have “more negative impact upon the infant brain than assaults from the nonhuman or inanimate, physical environment” (ibid, p 237).

The social ecological model considers behaviour from the perspective of continuous interactions within nested systems, from individual, interpersonal, organisational, community, through to intercultural factors. In our child development focus these systems might be from the maternal dyad, father and sibling relationships, extended family and kinship group, family friends, school, neighbourhood, friends, church or sporting groups, work or shops, through to public services and federal elections. Over time, development occurs through widening ripples through these areas.

The family must also interact constructively with the extended family and neighbourhood, allowing the child to learn citizenship, safe behaviour and how to live independently in a human community. In a very practical sense it is important for the family to facilitate the child’s independence and learning at school, to make effective use of health and medical services, and to develop constructive peer relationships.

The NSW Child Deaths Committee (2000) raised specific concerns when a parent is drug-affected, particularly by methadone, and if the child is aged less than 12 months. Parental abuse of alcohol and other drugs has contributed to children’s deaths from dehydration, pneumonia, bronchiolitis, toxicity, drowning and motor vehicle accidents. It is also associated with social isolation, poverty, domestic violence, parental mental illness, parental personality disorder, single parenthood with serial partners, inadequate support networks, criminal activity and involvement in drug-using networks.

The Denver Group (Steele and Pollock, 1974) identified characteristics of abusive parents:

Crittenden, 1988, found:

A recent review ^[14]of some Authorised Clinicians’ reported summaries of their findings found high levels of disability (broadly defined), alcohol and other drug misuse, violent behaviour problems and mental illness for the parents of the at-risk children.

Figure 2. FIGURE 2: Proportions of problems found in parents of children and young persons (0-18 years).

I hope this summary has shown why it is not possible to assess either a child or a parent alone. Each needs to be understood in relation to the other. My model of assessment of parenting capacity^[15], from which the following information is drawn, attempts to allow the interactions between the child’s needs and the parents’ resources to be considered. It is based on considering the parenting dimensions that relate to these needs (Steinhauer 1991, Mrazek et al, 1995, Brennan 1996, Azar et al, 1998).

Stafford and Zeanah (2006) have summarised the essentials of parenting as involving the provision of sustenance, stimulation, support, structure and surveillance. We need to operationalise what these may mean, particularly for vulnerable children.

Assessments of parenting capacity need to reflect the fact that the majority of carers are women (Wyndham 2008). When separated fathers are assessed for parenting capacity, it is often their new partners who are expected to do the work.

Allerton M Assessment of Parenting Capacity, 2012.

Bonomi AE et al “Health care utilization and costs associated with childhood abuse” (2008) Journal of General Internal Medicine 23(3), pp 294–9.

Brennan J Assessment of Parenting Capacity. talk given to DoCS psychologists at Parramatta, 1996.

Bretherton I “Emotional availability: an attachment perspective” (2000) Attachment and Human Development 2(2), pp 233–241.

Bronfenbrenner U The ecology of human development Harvard University Press, Cambridge, MA, 1979.

Carr S and Francis A “Childhood maltreatment and adult personality disorder symptoms in a non-clinical sample” (2009) Australian Psychologist 44, pp 146–155.

Conroy E et al “Child maltreatment as a risk factor for opioid dependence: comparison of family characteristics and type and severity of child maltreatment with a matched control group” (2009) Child Abuse & Neglect 33(6), pp 343–352.

Crittenden PM “Dangerous behavior and dangerous contexts: a thirty-five year perspective on research on the developmental effects of child physical abuse” in Trickett P (ed) Violence to Children American Psychological Association, Washington DC, 1998, pp 11–38.

Crittenden PM Raising parents: attachment, parenting and child safety Willan Publishing, Cullompton UK, 2008.

Donald T and Jueridini J “Parenting capacity” (2004) Child Abuse Review 13 pp 5-17.

Fonagy P, risk and protective factors within early development, as linked to social inequalities (personal communication) 1998.

Fonagy P “Attachment, Reflective Function, Conduct Disorders and Violence” at <www.psychol.ucl.ac.uk/psychoanalysis/zipped/sanfrancisco.rtf>, 2000.

Kerr MA Black MM and Krishnakumar A “Failure-to-thrive, maltreatment and the behavior and development of 6-year-old children from low-income, urban families: a cumulative risk model” (2000) Child Abuse & Neglect 24(5) pp 587–98.

Lamont A Effects of child abuse and neglect for children and adolescents National Child Protection Clearinghouse, Australian Institute of Family Studies, 2010.

Lauretti A, Loding B “The evaluation of parental fitness in termination of parental rights cases: a functional-contextual perspective” (1998) Clinical Child and Family Psychology Review 1 pp 77–100

Martin HP (ed), “The abused child: a multidisciplinary approach to development issues and treatment”, Ballinger Publishing Company, Cambridge MA, 1976.

McLewin LA and Muller RT “Attachment and social support in the prediction of psychopathology among young adults with and without a history of physical maltreatment” (2006) Child Abuse and Neglect 30 pp 171–191.

Mrazek D, Mrazek P and Klinnert M “Clinical assessment of parenting” (1995) Journal of the American Academy of Child & Adolescent Psychiatry 34(3) pp 272–282

NSW Child Death Review Team 1999-2000 Report, NSW Commission for Children and Young People, Sydney, 2000.

Schore, AN Affect dysregulation and disorders of the self, The Norton Series on Interpersonal Neurobiology, WW Norton & Company, New York, 2003.

Steele BF and Pollock CB “A psychiatric study of parents who abuse infants and small children” in Helfer R and Kempe CH (eds) The Battered Child, 2nd ed, University of Chicago Press, Chicago, 1974, pp 80–133.

Stafford BS and Zeanah CH, “Attachment disorders” in Luby, JL (ed) Handbook of preschool mental health: development, disorders, and treatment, The Guilford Press, New York, 2006.

Steinhauer P The least detrimental alternative: a systematic guide to case planning and decision making for children in care University of Toronto Press, Toronto ON, Canada, 1991.

Wyndham, A, (personal communication) 2008.