John was a superficially charming fourteen-year-old lad with bright red hair and a ready smile. I met John soon after I began my first appointment as a Clinical Psychologist. John was a Ward of the State. He was referred to me because statutory social workers who were responsible for his care were concerned about his volatile and at-risk behaviours. John had made a number of suicidal gestures, was often AWOL from the facility at which he resided and was known to abuse substances. John was also suspected of being involved in child prostitution.
I had never before met anyone like John and was not entirely sure what to do with him. Though I did not know it at the time, I had received my first referral of an "attachment-disordered" youth. My next step was also my first in a career specialisation in the diagnosis and treatment of attachment-disordered children.
I read a book. It was Richard Delaney's Fostering Changes. This was my first introduction to the world of the attachment-disordered child, and in particular, their world view. I discovered that attachment-disordered children do not see themselves, others and the world in which we live as we, who were blessed with accessible, understanding, responsive and attuned parents, see the world. Rather, they predominantly see themselves as bad and unlovable, others as mean and uncaring, and the world as a harsh and threatening place.
I then began to wonder about what I had been taught during six years of training at university. I had never heard of attachment disorders in an academic environment dominated by behavioural and cognitive-behavioural theories and models of practice. And then one day it occurred to me that one of the most famous series of experiments in psychology, a series of experiments that informed academic and applied psychology for half a century, was directly relevant to the experience of the attachment-disordered child, and our understanding of them.
The series of experiments involved placing rats in a box that contained a lever-operated feeding Shute. Rats were exposed to one or another of three "learning conditions". Rats in the first condition received a food pellet each time they pressed the lever. Rats in the second condition received a food pellet inconsistently when they pressed the lever. Rats in the third condition never received a food pellet when they pressed the lever. Research has consistently shown that in these kinds of experiments, rats who receive a food pellet inconsistently press the lever at the highest rate and the most persistently, whereas those who never receive food pellets soon stop pressing the lever.
The relevance of this to attachment-disordered children is as follows. Attachment disorders are thought to develop in care environments akin to conditions two and three of the above experiments; that is, care that is inconsistent or largely absent. Like the rats in the experiments, attachment-disordered children exhibit high frequency and persistent attempts to gain access to basic needs provision. They also resort to unconventional methods of doing so. They are inordinately demanding, manipulative and self-reliant. They exhibit an apparent preoccupation with accessibility to basic needs provision.
So all you need to do is place the attachment-disordered child in a care environment where their basic human needs are responded to in a consistent manner and they will be less demanding, coercive and self-reliant? Right? Wrong! I soon noticed that attachment-disordered children continued to be demanding, coercive and self-reliant in foster care (and, later, in adoptive) placements where their needs were responded to in a more consistent and predictable manner. Did they not understand that they no longer needed to be so preoccupied and controlling? This question is only partly answered by the finding that rats who receive food inconsistently are slow to learn when the condition under which food is provided changes.
The next step in my professional development involved understanding the effect of inconsistent needs provision on the developing brain and coincided with the birth of my eldest child. My son was a small baby who demand fed and had early difficulties suckling. Across his first year he was slow to settle to sleep and, once my wife returned to paid employment, he experienced recurrent bouts of tonsillitis in association with time spent in childcare. Whether due to feeding difficulties, sleeping difficulties or illness, he regularly became distressed and required attentive, creative and loving care to ensure that he (and us) was happy most of the time.
So what about infants who do not receive attentive, creative and loving care when they are distressed? The work of Bruce Perry and his colleagues revealed to me what was likely to be happening to the developing infant brain under conditions of recurrent, persistent and unresolved emotional distress. This latter part of my professional journey has spanned more than fourteen years and along the way I have learnt the following:
That children who were frequently distressed and inconsistently soothed during infancy are prone to feeling overwhelmed and the activation of our in-built coping mechanism for managing the source of these feelings: the fight-flight-freeze response;
That the fight-flight-freeze response occurs when there is reduced blood flow to the parts of the brain that control logical thinking and effective action and increased blood flow to the parts of the brain that control instinctive, survival responses;
That many aberrant behaviours exhibited by children are associated with partial or full activation of the fight-flight-freeze response, including controlling, aggressive and oppositional behaviours (fight), running and hiding (flight), and withdrawn and uncommunicative behaviour (freeze);
That behaviours associated with the fight-flight-freeze response are only partly volitional or totally non-volitional, depending on the child's level of distress;
That the way in which adults in a caregiving role respond to these behaviours either escalates (disciplinary response) or de-escalates (calming response) these behaviours; and
That their history of inconsistent, abusive and/or frightening care ensures that attachment-disordered children are particularly prone to feeling overwhelmed and associated fight-flight-freeze behaviours.
So, after several years of working closely with these children I understood that the essential characteristics of the attachment-disordered child are that they acknowledge and/or display behaviours that reflect the following:
Predominantly negative or pessimistic beliefs (attachment representations) about themselves, about others, about relating to others and about the world in which they live;
An enduring and all-encompassing preoccupation with accessibility to needs provision; and
Chronic susceptibility to feeling overwhelmed and the associated fight-flight-freeze response.
What next? Fortunately, my years of training had granted me one particular skill set: the ability to communicate empathy. Often referred to active listening or counselling skills, these involve observing and listening closely to the individual in front of you and communicating understanding of what is in their head and in their heart in our words and in our non-verbal expressions. And thanks to my earlier reading, I had some idea of what was in the mind and the heart of the attachment-disordered child. And so I started to say these things to them, and in doing so I was offering them an experience of their inner world being understood and validated that was akin to what an infant experiences when they are fed when they are hungry, changed when they are dirty and soothed when they are distressed. Further, I was offering them the experience that their opinions and feelings were understood and important, that people can be sensitive and kind, that relating to others can be a satisfying experience, and that the world may not be such a bad place after all. In short, I was beginning to change their attachment representations.
Not that it has all been smooth sailing! I vividly remember a worker from the local disability authority bringing an attachment-disordered lad to see me. She sat in our session and was exposed, perhaps for the first time, to focused and sustained acknowledgement of the lad's very negativistic view of all things. Whereas he warmed very quickly to the approach and spontaneously disclosed his heretofore very private (and deeply concerning) thoughts and feelings on a number of topics, she was horrified and sought to divert the session to a discussion of the lad's positive aspects. It occurred to me that if her approach worked there would have been no need to refer the lad to me. I already understood that you cannot convince a person about their positive attributes when the person does not believe their positive attributes to exist by simply telling them that they do. Any such attempt is easily dismissed by the attachment-disordered child and explains why they are typically unresponsive to praise. Rather, you need to make them feel positively about themselves first, and communicating understanding does just that. It also promotes verbal expression in the attachment-disordered child and reduces the likelihood of them acting out aspects of their inner world.
Oh, and I never saw the lad again.
Some time earlier I was on a home visit to a four-year-old child and his foster mother. I observed her to be a skilled and attentive caregiver. I observed him to be demanding and jealous of her attention being bestowed elsewhere. I heard about his intense separation anxiety and associated difficulties with settling to sleep in his own bed. It occurred to me that, no matter how diligently his foster mother responded to his requests and demands, he was not satisfied. Reflecting on his known history of neglect prior to his placement in foster care, it also occurred to me that he had never learnt that he could rely on adults in a caregiving role to understanding his needs and respond consistently to them. He was preoccupied with his needs and with controlling his caregiver in order to reassure himself that he could access needs provision. So how could we convince him that he did not have to be so preoccupied, so jealous and so demanding when his caregiver was forever responding to his demands for need provision? Well, I reflected on how an infant ordinarily learns this and concluded that his caregiver needed to anticipate his needs and respond to them before he did anything to make it so. When attachment-disordered children experience needs recognition and provision without doing anything to make it so, they begin to learn that they can rely on others and become less preoccupied with their needs.
Finally, although understanding and proactive caregiving are inherently soothing, it does not hurt to engage in direct measures to reduce an attachment-disordered child's propensity to feel overwhelmed. In caring for my own children as infants I observed the powerful effect of certain forms of classical music, played softly at bedtime, in facilitating a state of readiness to go to sleep. Certain research attributes to music a powerful role in promoting a state of calm readiness, whereupon we are more likely to perform at our best and less likely to feel overwhelmed by the challenges of the day. So how do we get the attachment-disordered child to listen to soothing classical music? The answer is to play it quietly in their bedroom while they sleep! They sleep more restfully, waken happier and better-tolerate the challenges of the day ahead.
