Child and Adolescent Mental Health Volume 11, No. 3, 2006, pp. 128–134 doi: 10.1111/j.1475-3588.2006.00393.x

Developmental Attachment Psychotherapy with Fostered and Adopted Children

David Howe School of Social Work and Psychosocial Sciences, Elizabeth Fry Building, University of East Anglia, Norwich, NR4 7TJ, UK. E-mail: [email protected]

Developmental attachment theory and research is now beginning to inform practice, particularly in the field of foster care and adoption. A brief outline of attachment theory and the four main patterns of attachment is followed by a review of attachment-based support services and psychotherapies with fostered and adopted children, including infants, preschoolers, school age children, and caregivers. Particular attention is given to the behaviour, defensive strategies and developmental needs of fostered and adopted children with pre-placement histories of abuse and neglect.

Keywords: attachment; psychotherapy; foster children; adopted children

Introduction explaining that ‘young minds form in the context of close relationships’. Thus, as carers help children make The goal of the attachment system is protection at times sense of their own and other people’s behaviour by of danger. Attachment is one of a number of proximity recognising that lying behind actions and behaviour are seeking behavioural control systems, which also in- minds, mental states and intentions, a whole train of clude affiliation, sexuality and caregiving. Attachment psychosocial benefits accrue, including emotional behaviours are triggered whenever the highly vulner- attunement, reflective function, social cognition, emo- able human infant experiences anxiety, fear, confusion, tional intelligence and interpersonal competence. It is or feelings of abandonment. Distress signals, such as these developmental and relational insights that crying, either bring the sensitive carer to the child, or if underpin and inform most attachment-based therapies. the child has locomotion, get the child to the carer. In Children whose carers are responsive and available this sense, the primary caregiver, destined to become at times of need and who are sensitive and emotionally the child’s selective attachment figure, acts as a secure attuned are likely to be classified as securely attached. base, a haven of safety. With maturation, these children develop mental repre- As the young child seeks proximity with her attach- sentations (internal working models) of themselves as ment figure, she is likely to be in an emotionally dys- loved and worthy of that love, and a complementary regulated state. Thus, as well as acting as a secure model of others as available and loving, understanding base, sensitive caregivers also help their child regulate and interested, particularly at times of need. Children and manage arousal and distress. There is a strong view who experience secure attachments therefore are likely that attachment is primarily a regulator of emotional to enjoy healthy psychosocial development, improved experience, including physiological arousal (Schore, social cognition, and raised levels of resilience based on 2001a). Within the affective exchanges between parents high self esteem, self-efficacy and coping capacity. and infants, children begin to build up an under- However, in the case of insecure children, the avail- standing of how their own and other people’s minds ability, sensitivity and responsivity of carers at times work at the emotional, intentional and behavioural of need is not so straightforward (Howe et al., 1999). level, and how these mental states affect social inter- Avoidant and ambivalent children defensively have to action and relationships. organise their attachment behaviour to increase the The more open, reflective, undefended, curious, fas- availability of their carer at times of need and distress. cinated, emotionally attuned and communicative the These adaptive strategies involve downplaying or carer is about her child’s mental state, the more the excluding some types of psychological information from child feels understood. The more understood the child conscious processing. This affects the individual’s feels, the more understanding she has of her own and ability to cope in a fully rounded and reflective way with other people’s psychological make-up. Therefore, carers the normal range of stresses met in social relationships. who see and acknowledge the child’s mind at work help Avoidant (defended) children (whose carers become their child develop mindful qualities. Following Fonagy anxious and rejecting whenever others place emotional and colleagues (2002), the parent’s capacity to observe demands on them) cope and adapt by excluding the child’s mind seems to facilitate the child’s general attachment-based feelings and behaviours from understanding of minds, and hence her self-organisa- conscious processing. Displays of need, weakness, tion through the medium of a secure attachment. dependency, and vulnerability in the self or others, Indeed, Schore (2001a) puts it even more forcefully make them anxious and avoidant. In order to

Ó 2006 Association for Child and Adolescent Mental Health. Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA Developmental Attachment with Fostered and Adopted Children 129 be acceptable and increase the other’s availability, they to increase the carer’s availability, hence the classifi- become emotionally self-contained but astute observers cation of disorganised attachment (Main & Solomon, of other people’s feelings and behaviour. More extreme 1990). avoidant strategies are used by children who suffer Developmentally, abused and neglected children rejection, abuse and psychological maltreatment. For with disorganised attachments suffer more complex example, physically and emotionally abused children and profound impairments as they experience the typically do not seek comfort or safety when upset, ill, worst elements of both avoidant and ambivalent vulnerable, or frightened. They have learned that care caregiving environments. In effect, they experience and protection are not unconditionally available, and unpredictable danger and abandonment over which, that being in a state of need only seems to make matters as infants, they have little control and can develop worse and might even make the carer more dangerous. no attachment strategy. Emotional arousal and the Trust in the availability, care and interest of others is attachment system remain acutely and chronically largely absent. This means that any relationship in activated. Much mental time and energy is spent on which there are attachment-related issues will trigger issues of safety, security and monitoring, leaving less feelings of anxiety, distress and aggression. Children time for exploration and pleasurable interaction with who experience extreme tension, stress and rejection in their caregiver. Being the cause of their children’s the parent-child relationship can even suffer growth distress, and being caught up in their own anxiety failure and poor physiological health. For children and dysregulation, these parents fail to perceive and classified as avoidant, the therapeutic aim is to help emotionally attune with their children’s distressed children access, admit, acknowledge, explore and re- mental states at the very time the children most need flect on their own feelings, especially those involving to feel safe, recognised, understood, contained and need and vulnerability. regulated. Children therefore fail to develop coherent Ambivalent (resistant, dependent) children (whose models and mental representations of their own or carers are inconsistent and poor at recognising other other people’s psychological make-up, and so find it people’s needs and attachment signals) cope and adapt difficult to regulate their own arousal or deal reflect- by maximising their distress and attachment behaviour ively with their own needs. It is this group of children to increase their chances of getting noticed. Their who are most at risk of developing behavioural prob- greatest anxiety is being ignored, abandoned and left lems (including aggression), psychopathology, and alone with needs unmet and arousal unregulated. They being placed in foster or adoptive care (Howe, 2005). live in an unpredictable world, in which there seems no With maturation, disorganised children do manage to guarantee that others will be there or respond at times develop fragile and more coherent representations of of need and distress. They have little confidence in their themselves as less helpless or at the mercy of others. own abilities to bring about change and get the things With carers who are unavailable and frightening, chil- they need. This results in a passive and fatalistic atti- dren begin to take control of their own safety and needs. tude to events; an anxious preoccupation with other This results in various controlling strategies, including people’s inconsistent emotional availability; and an compulsive compliance, compulsive caregiving, com- angry, demanding, dissatisfied, needy, pleading, and pulsive self-reliance, and coercion as the child out- provocative approach to relationships. There is little manoeuvres the parent and controls their availability monitoring of one’s own behaviour or emotional condi- by switching between threatening/aggressive and dis- tion. More pronounced versions of this attachment arming/helpless behaviours (Crittenden, 1995, 1997). strategy are met in some types of chaotic neglect. Under These are very partial, incomplete and brittle strategies stress, children feel helpless. Their immaturity, impa- that quickly break down under stress leaving the child tience and impulsivity mean that they repeatedly ‘go too once more frightened, angry, sad and highly dys- far’. Underpinning all their behaviour is the drive to be regulated. The therapeutic aim for these children (and noticed, valued, acknowledged, and recognised. They their parents) is to help them feel safe enough to act as if always in a crisis (Crittenden, 1999). This recognise, acknowledge and process their emotions, produces children who are demanding and yet never both at the psychological and physiological level. They satisfied or reassured. The therapeutic aim is to help only feel safe when they are in anxious control, but this children stop and reflect, structure their thoughts, feel strategy denies them experiences designed to help them valued and worthwhile, and think through the causes look at, understand, and handle their own and other and consequences of their feelings and behaviour. people’s minds. Children also need to learn to trust that new carers will be sensitively available at times of vulnerability and dependence; that they will not be overwhelmed by Interventions with foster carers and adoptive emotional need. parents The group that finds it most difficult to organise an Post-placement support attachment strategy is children whose carers are the The provision of substitute parents in itself represents direct cause of their distress and fear. Attachment fig- the most radical, comprehensive and potent therapeu- ures who frighten; menacingly threaten, physically and tic change in a child’s psychosocial prospects. The most sexually abuse, and abandon their children; or behave effective therapeutic focus, particularly with younger in a helpless and dysregulated way when faced with children, is to work with and through the new carers. their children’s attachment needs, these parents are Therefore, the first level of intervention needs to ensure both the source of fear and the supposed solution to that carers are sufficiently stress free and reflectively that fear. Within such caregiving environments, chil- open in order to be psychologically available, attuned dren find it difficult to organise an attachment strategy 130 David Howe and responsive to the placed child’s developmental relationship. This empathic match or affect synchrony needs. Adoption and foster care research repeatedly operates both inside and outside language; eyes, facial reports that good social support, whether from family or expression, voice, and body language are particularly the community, correlates with better placement out- important channels of communication for children who comes. More recent practices suggest that other foster have been maltreated and tend not to hear or process and adoptive parents can provide effective emotional words (Schore, 2001b). support, information, and the wisdom of their experi- The sensitive caregiving behaviours are potentially ence. Both individual telephone contact and group ‘mind-engaging’. They provoke in the child self-reflec- support have been found to be effective. tion and thoughts about the other. However, children who have suffered loss or been maltreated can be Educational support and training anxious and fearful of direct mind-to-mind communi- Adoptive and foster carers benefit from training and cation. They have learned to stay safe by not letting education about both normal and abnormal child other people impose and intrude their demands on development. Particularly helpful are programmes them (too dangerous), and by not exploring other peo- which increase parents’ knowledge about how adversity ple’s minds and perspectives (too frightening, too affects children’s development, behaviour and mental hurtful). Maltreated children will avoid emotional con- health. For example, work by Dozier and colleagues tact and robust psychological exchange until the rela- illustrates how children bring to their new placements tionship feels safe. Practitioners and therapists the insecure attachment strategies that have helped therefore have to proceed very gently, backing off if the them cope with and, to an extent, survive parental closeness, the movement, the psychological intimacy abuse and neglect (Dozier et al., 2002a, b; Dozier, seems to be too frightening. Fear will trigger defensive Lindhiem, & Ackerman, 2005; also see Schofield & manoeuvres, including dissociation, aggression, with- Beek, 2006). Many maltreated children find it difficult drawal and other compulsively self-reliant controlling to elicit sensitive and responsive care and protection. strategies. Children’s previous experiences and adaptations to When people begin to feel safe, memories and emo- hostile and helpless caregiving environments not only tions can enter consciousness and be accessed, affect their behaviour, but also affect new carers and acknowledged and processed more readily. We can put their caregiving. Therefore, attachment strategies that words to feelings. The more safe, contained and trusting are adaptive in one caregiving situation may become children feel, the more they are able to allow painful and maladaptive in another. Teaching carers (typically in difficult emotions to be contemplated. Interventions are supportive groups) about the adaptive strategies, therefore designed to increase young children’s security defensive manoeuvres, and attachment behaviours of attachment by improving parental sensitivity, mind- employed by abused and neglected children provides mindedness, responsivity, and involvement. This might them with a conceptual framework, not only better to be achieved either by changing parental behaviour as understand their children, but also to interact with they interact with their child or by shifting the carers’ them more sensitively and creatively (Marvin et al., own mental representations of attachment towards 2002; Schofield & Beek, 2006; Golding, 2003; Golding greater security and autonomy. Either way, treatment is & Picken, 2004; Allen & Vostanis, 2005; Adoption UK, directed at modifying the way in which parents process 2005). attachment-related information in relationship with their children. Behavioural guidance Behaviourally based attachment interventions seek Successful therapy with placed children who have suf- to improve parental sensitivity and the affect-commu- fered neglect or maltreatment needs to introduce them nicating capacities of mother-infant interactions. They to many of the skills and behaviours shown by sensitive guide parents as they interact with their children. carers whose children are classified as secure. The Treatments are designed to help carers see, understand regulation of emotional arousal is key to success, and and respond to their child’s signals, particularly their therefore affect regulation is a primary target of all distress signals. This is true even when children send interventions. Attachment-based therapies aim to sup- out the signal that they do not want nurturing even at port and develop further new parents’ capacity for em- times of distress. In these cases, there is the real risk pathy, mind-mindedness and reflective function. that the new carer will de-activate his or her caregiving. Fostered and adopted children with histories of loss, Dozier and colleagues have developed interventions neglect and abuse need help to get in touch with their that help carers ‘provide a nurturing relationship by feelings, to recognise them, consider their impact on self over-riding the natural propensity to respond in a and others, and begin to process them in a more complementary fashion to a child’s behavioral signals’ reflective, conscious, regulated way. Even so, some (Dozier et al., 2002b; Dozier, 2003, p.256; Dozier & emotions are difficult to bear and it may take some time Sepulveda, 2004). For example, ‘If the child appears and trust before they can be examined. In effect, par- angry when the caregiver attempts to soothe him or her, ents or therapists co-construct with children the key the caregiver is encouraged to see the behavior as features of a secure attachment in order to help them resulting from the child’s frustration with caregivers not recognise and regulate affect. Carers have to amplify being dependable in the past’ (Dozier et al., 2002b, what they feel and perceive in the child, in the manner p.547). Therapists can facilitate reflective function by of the secure parent-child relationship, to ensure that commenting on interactions between parent and child as much emotional and psychological information is that seem mis-cued, confusing or distressing by ‘asking conveyed to the child who is not used to receiving so the parent to stop and reflect on the thoughts and much interest and feedback in the context of a safe feelings that accompanied the negative interaction’ Developmental Attachment with Fostered and Adopted Children 131

(Kobak & Esposito, 2004, p.162). Through repeated use lay down expectations about how others will respond at of this ‘stop-the-action’ technique, parents are helped to times of need, and about how effective we feel in get better at monitoring, reappraising and repairing securing what we need from relationships. These their communications with an insecure child. organised mental representations of the self and others Videotaped parent-infant interactions are used to (as either positive or negative) are carried forward by help carers recognise their own positive responses and individuals and used to guide behaviour in subsequent interactions. By recognising their positive impact on the relationships. Internal working models (states of mind) placed child, parental competence and confidence is organise appraisal processes, thought, memory, and built up. As well as being helped to recognise, under- feelings with regard to attachment saturated situations, stand and communicate their child’s perceived affective including relationships with our children. state, new carers are also helped to follow their child’s New carers who have insecure states of mind with lead (in play, in conversation), in short to become more respect to attachment, and more particularly those who responsive social partners and improve the child’s have unresolved states of mind, are likely to find that sense of ‘agency’ (Dozier et al., 2005). the placed child’s attachment needs and behaviour A study by Juffer et al. (1997) evaluated an early activate old anxieties, defences, unresolved losses and intervention programme. The intervention aimed to traumas. This undermines their sensitivity and ability support parental sensitivity by promoting secure to attune affectively with the child (Hughes, 2002). attachments in a group of 90 mothers who had adopted Maltreated children placed with unresolved carers are a young child from another country. The mothers were likely to continue using their controlling/disorganised divided into three equal size groups. One received a attachment behaviours, with the increased risk that the personal book programme on how to practise sensitive placement will break down (e.g. Dozier et al., 2001; parenting, playful parenting, and holding and comfort- Steele et al., 2003). Required in these cases are inter- ing their child. The mothers’ observational skills were ventions that aim to change the carer’s representations enhanced by inviting them to describe and note down of attachment. Therapy aims to alter these distorted what their infants were doing. A second group was also representations by inviting parents to reflect on their given the book and advice about sensitive and respon- past and present attachment and experiences. This is sive parents, but in addition mothers received three achieved by asking parents to explore what they bring sessions of video-feedback. Each mother was shown a from their own relationship with their parents to the short video of her interaction with her infant. Sensitive relationship they have with their own child. Group work responses were noted and reinforced with positive with other parents might also be used to support and comments, including those that seemed to have a par- strengthen reflective function (e.g. Marvin et al., 2002). ticularly beneficial effect on the child. The practitioner Juffer, Bakersman-Kranenburg, & van IJzendoorn also verbalised the infant’s signals and expressions to (2003) also note that the practitioner is required to act give a sense of what the child might be thinking, feeling as a secure base during this exploratory and reflective and doing. There was also a control group who were gi- process. ven just a brochure about adoption. Twelve months la- ter, both the mothers who received the book-based programme and those who also had the video-feedback Joint interventions with carers and placed showed higher levels of sensitivity and had more se- children curely attached children than the control group. Many of the original attachment-based therapies were Dozier and colleagues (2002b; 2005) have developed developed by practitioners who believed that the pre- an intervention that targets foster carers (‘Attachment dominant attachment behavioural pattern for fostered and Biobehavioral Catch-up’, currently under investi- and adopted children with histories of maltreatment gation in a randomised control trial). The 10 thera- was a ‘controlling/disorganised’ one, including for the peutic sessions are administered in the parents’ homes most severely maltreated children the likelihood that and involve the caregiver and child interacting. Ses- they would sometimes show dissociative behaviours. sions are videotaped. The first two sessions help carers Children would continue to use these attachment re-interpret children’s behavioural signals in terms of strategies in their new placement. In effect, this meant attachment and the need to feel protected and cared for that children continued to hold mental representations at times of distress. The third session encourages foster of carers as potentially hostile or helpless, and therefore carers to improve children’s sense of agency by helping unavailable as sources of protection or regulation. them follow their child’s lead during interactions. Later Placed children had learned to survive by not letting sessions give parents the opportunity to recognise and carers be in a position of care or control. And so, iron- reflect on both their own and their child’s displays ically, the more new carers behaved like carers, that is and experiences of attachment influenced behaviour the more they sought to comfort and get close to chil- and emotional states, particularly in terms of how past dren at times of upset and need, the more distressed, attachment-related experiences are played out in the defensive and controlling children became, thus deny- present. ing them experience of the very thing that would help them feel safe, understood and regulated. Changing the parent’s mental representation/ The therapeutic task, therefore, was to help children working model of attachment feel safe and trust their new carers. The aim was to help Representational models of therapy aim to bring about children let go of their ‘controlling’ defensive behaviours more positive internal working models that generally so that they could access the sensitive, affectively lead to more sensitive, autonomous caregiving. In the attuned caregiving being offered by their new carers. light of our relationship history, mental representations One early interpretation of this task by some therapists 132 David Howe was to argue that defensively controlling children (1997, 1998, 2003, 2004), for example, has fashioned a needed intense exposure to the safety and value of treatment model (Dyadic Developmental Psychother- sensitive caregiving (a kind of flooding technique). In apy) based on reciprocal experiences between parent some hands, this lead to the practice of ‘holding and child that are ‘affectively and cognitively matched therapy’, which has been heavily criticised by most to the developmental, age-appropriate needs of the attachment theorists who suggest that such a treat- child’ (Hughes, 2002). The treatment and parenting ment is incompatible with attachment theory (e.g. model includes teaching carers the importance of O’Connor & Zeanah, 2003; Boris, 2003). Instead, what attuned and sensitive eye contact, voice tone, touch is recommended is continuous and prolonged exposure (including nurturing-holding) and gestures that com- to consistent, sensitive, affectively attuned caregiving. municate safety, acceptance, curiosity, playfulness, Over time, children’s experience of safe, empathic, and empathy (Hughes, 2004). Older children are reliable parenting allows them to disconfirm their old also helped to make sense of their history and how this mental representations of carers as dangerous and/or plays out in their current behavioural and emotional helpless replacing them with more secure, available functioning. models of caregiving at times of need. In practice, this Similar to secure parent-infant interactions, therapy approach has produced three linked interventions. involves helping parents react contingently, collabor- atively and with sensitivity as children experience af- Sensory integration techniques and other fect-laden material. They track and react to the child’s developmentally-based treatments emotional state. Fonagy et al. (2002) describe this as Many abused and neglected children have suffered ‘mentalised affectivity’, something rather like ‘affect sensory deprivation in the context of non-sensitive mirroring’ which takes place between mothers and caregiving. They display a range of physical, sensory babies. When employed therapeutically, the child’s and emotional impairments. Balance can be affected emotional, mental and somatic states are recognised, (making children very accident prone). Perception and named and mirrored back verbally, facially, in gesture processing of sight, sound, touch, taste, smell, and the and body posture. Mentalised affectivity is present in relationship between emotional experience at the children when they begin to recognise the way their own somatic and psychological level can be upset. For and other people’s affective states affect both parties’ example, an intense and unexpected physical stimulus feelings, thoughts and behaviour. ‘In successful ther- can act as a reminder of past abuse causing the child to apy, the client gradually comes to accept that feelings become extremely distressed. Using sensory integration can safely be felt and ideas may be safely thought about’ techniques (based on the provision of multi-sensory (Fonagy, 1998 cited in Allen, 2001, p. 310). Mentalised and stimulating environments), children begin to affectivity therefore feeds the incoherent, unintegrated develop a more integrated understanding of how their mind with powerful and valuable information about its bodies and senses work (e.g. Ayers, 1989). Until chil- own state. dren have learned to organise sensation, they find it difficult to move to the next stage of emotional develop- Helping children to feel safe when they relinquish ment. Elements of Fisher and Chamberlain’s (2000) their ‘controlling’ behaviours Early Intervention Foster Care project also help chil- The third therapeutic strand helps ‘controlling/dis- dren regulate their bodies as well as their minds. organised’ children lower their defences so that they can access and engage with their carer’s mind. Parents The provision of sensitive, emotionally attuned are taught a range of techniques that help children feel caregiving safe even when the parent is in charge. Essentially, Many attachment-oriented clinicians believe that new children are given ‘choices’ and some sense of control, parents have to understand that in order to ‘connect’ although these choices are determined by parents. It is with their defended child, they may have to interact at lack of control, predictability and structure that makes the developmental age of the child and not the chro- traumatised children feel that situations are getting nological age, particularly at times of distress and high dangerous (Perry, 1999). Children who have been neg- arousal (Schore, 2001b; Holmes, 2001; Howe & lected and abused should be provided with clear and Fearnley, 2003; Levy & Orlans, 1998; van Gulden & full information about present and future events, Bartels-Rabb, 1995). This requires a heightened degree repeated as often as necessary. Uncertainty distresses of sensitivity, accurate, exaggerated and repeated children with a history of maltreatment. Dozier and feedback about the child’s emotional condition (as you colleagues have also developed techniques that help would with a baby or toddler). There is emotional con- carers generate situations that children can experience gruence and co-regulation of affect. All this is conduc- as controllable by teaching parents to follow their ted in the context of a structured, warm, predictable, child’s lead (Dozier & Sepulveda, 2004). contingent caregiving environment that is particularly responsive to the child’s signals (Perry, 1999; Dozier Conclusion et al., 2002b; Fisher et al., 2000). This promotes children’s ability to self-regulate. Attachment theory and research have run ahead of Most attachment therapists therefore recognise that practice.Evidence-basedinterventionsaremostdevelop- treatment somehow has to replicate the developmental ed in the case of infant and young child placements (for characteristics of secure caregiving, but with a child example, see Berlin et al, 2005). Good quality de- who deeply mistrusts being looked after, cared for and scriptive clinical experience is available for therapeutic protected by his or her ‘attachment figures’. Hughes work with older placed children but this is only now Developmental Attachment with Fostered and Adopted Children 133 being subjected to trialled evaluation. Underpinning Fisher, P., & Chamberlain, P. (2000). Multidimensional treat- most attachment-based interventions for fostered and ment foster care: A program for intensive parenting, family adopted children is the recognition that sensitive and support, and skill building. 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