Working with vulnerable infants

D E C E M B E R 2 0 0 738

02 Editorial

05 Marie Connolly, Philippa Wells and

Jo Field examine the needs of vulnerable

infants when they come to the notice of Child,

Youth and Family

11 Nicola Atwool discusses how secure

attachment acts as a protective factor for

infants, parents and caregivers

21 Megan Chapman and Jo Field look at

engagement with vulnerable families and the

importance of practice depth

29 Emily Cooney and Kirsten Louden-Bell discuss

post-traumatic stress disorder and borderline

personality disorder in the child welfare

population

36 Book reviews

39 Information for contributors

Social Work Now is published three times a year by Child, Youth and Family.

Views expressed in the journal are not necessarily those of Child, Youth and Family. Material

may be reprinted in other publications only with prior written permission and provided the

material is used in context and credited to Social Work Now.

DECEMBER

2 0 0 7

38

SOCIAL WORK NOW: DECEMBER 2007

Vulnerability and child protection

Pat Tuohy

02

I am delighted to introduce this special edition

of Social Work Now on vulnerability.

Vulnerability is a topical concept in current

social policy discourse about children and

families. The idea that population groups can

be regarded as vulnerable is relatively new, and

the application of the term is variable in scope

and meaning. In a recent article, Mechanic and

Tanner (2007) claim that before the late 1980s

the term was not used in this context.

The dictionary meaning of ‘vulnerable’ includes

“open to emotional or physical danger or harm;

exposed to an attack or possible damage; unable

to resist illness, debility, or failure” (Encarta

World English Dictionary, 1999). However, as with

many words which are evolving new meanings,

it is sometimes used to mean the ‘at-risk’ child

or family; families with ‘high needs’; families

living in poverty; or dwelling in high deprivation

areas. All of these definitions are incorporated,

sometimes without sufficient analysis, into policy

responses to vulnerable families and children.

This variability in the meaning of ‘vulnerable’

in the current child protection literature and

its increasing use in social policy, suggests

that there is an urgent need to refine the term

‘vulnerability’ as it is applied to children and

families, so that the concept is meaningful

across agencies and professional groupings.

According to Mechanic and Tanner, vulnerability

encompasses a number of dimensions, which

can be summarised as the relationship between

individual capacities and actions on one hand,

and the availability of support and social capital

on the other. This range of dimensions mirrors

the public health model of social determinants

of health (Dahlgren & Whitehead, 1991), which

identifies individual and social variables that

interact to influence health outcomes.

With respect to individual capacity,

vulnerability can be understood as genetically,

environmentally and socially determined.

Recent research into the field of gene/

environment relationships has suggested that

complex relationships exist between all of these

factors. For example, we now know that genetic

variants can modify the effects of exposure to

an environmental influence. A recent article

from the Dunedin Multidisciplinary Study

investigated the role of a genetic variant in a

neurotransmitter-metabolising enzyme on the

subsequent development of antisocial behavior in

children who have been maltreated (Caspi et al,

2002). The researchers found that abused children

whose gene variant provided high levels of gene

expression were less likely to develop antisocial

problems. This paper and others like it suggest

that possession of variant genotypes affects a

child’s sensitivity to environmental factors.

EDITORIAL


In the area of child protection the

differentiation between risk and vulnerability is

crucial, and failure to recognise the difference

leads to inappropriate policy responses and

ultimately ineffective interventions. An example

of the confusion in this area is the growing

support for screening for child abuse on the

basis of ‘risk factors’. The risk factor approach

has been used in many areas to identify high-

risk individuals and target interventions or

further investigations to these groups. We are

all familiar with successful medical screening

programmes, such as those for newborn

metabolic disease (the

Guthrie test), and breast

and cervical screening

programmes. Many studies

have attempted to screen

families to determine whether

a parent was likely to abuse

their infant or child. None

have managed to develop

a screen that has sufficient

validity. The Canadian Task

Force on Preventative Health

Care (MacMillan, 2000) notes

that there is sufficient evidence to exclude

screening procedures aimed at identifying

individuals at risk of experiencing or committing

child maltreatment.

The medical and child protection research also

describes a range of ‘risk factors’ for abuse.

These factors range from societal (poverty,

socioeconomic and educational status), through

community (geographic or demographic

characteristics), to parent or caregiver (drug and

alcohol abuse, single parenthood), and finally

child factors such as prematurity, disability and

personality characteristics.

In reality, this spectrum of ‘risk factors’ is a

characteristic marker of vulnerable populations.

03

Social capital and support (or the lack of) form

the other components of the vulnerability

continuum, and describe the networks and

processes within communities that support

people and build solidarity, and enable healthy,

strong and resilient communities to develop.

Community development approaches can build

social capital and support, but may not be

considered in policy responses to vulnerable

families. Service provision at an individual

level (the caseworker approach) is often the

first response of government agencies, as they

attempt to address community vulnerability.

However if agencies do not

build social capital and

support, this can lead to

increasingly disempowered

and dependent communities,

whose members are unable

or unwilling to take

responsibility for creating

healthy environments for

their members.

Given the complex nature of

vulnerability, how should we

respond to child abuse and maltreatment? Our

first step should be to clearly differentiate the

concepts of ‘risk’ and ‘vulnerability’. Lupton

(1999) argues that the technico-scientific

approach to risk “bring[s] together the notion of

danger or hazard with notions of probability”

(p. 17). Risk in the commonly used medical

paradigm describes an increased likelihood

of specific adverse outcomes, which can be

identified and quantified, mitigated or accepted.

Mechanic and Tanner conceptualise vulnerability

as a more subtle and complex state of being

that has a range of components, ranging from

individual (personal limitations and actions)

through to relationships (social networks and

social support), and societal and environmental

factors (location, poverty and ethnicity).

In the area of child protection the

differentiation between risk and vulnerability is crucial,

and failure to recognise the difference leads to inappropriate policy

responses and ultimately ineffective interventions

SOCIAL WORK NOW: DECEMBER 2007 04

maltreatment, we must ensure that a common

social construct of vulnerability is recognised by

a range of social service agencies. An integrated

public health based programme that supports

vulnerable communities and families to build

individual capacity, social capital and support,

is a sound future direction for the prevention of

child abuse.

The papers in this edition address a range

of areas with respect to vulnerability. By

focusing our collective efforts toward reducing

disadvantage in society, we will support an

integrated public health based model.

R E f E R E n C E s

Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I. W., Taylor, A., & Poulton, R. (2002). Role of Genotype in the Cycle of Violence in Maltreated Children. Science, 297, 851-854.

Dahlgren, G., & Whitehead, M. (1991). Policies and strategies to promote social equity in health. stockholm: Institute for future studies.

Lupton, D. (1999). Risk. Abingdon: Routledge.

MacMillan, H. L. (2000). Preventative health care - update: prevention of child maltreatment. Canadian Task Force on Preventative Health Care.

Mechanic, D., & Tanner, J. (2007). Vulnerable People, Groups and Populations. Societal View Health Affairs, 26, no.5 (2007), 1220-1230

Ottawa Charter for Health Promotion. (1986). first International Conference on Health Promotion. Ottawa, 21 november.

Pat Tuohy is Chief Advisor,

Child and Youth Health, at the

Ministry of Health.

He is a specialist paediatrician

with a particular interest

in community child health,

child health policy, and

developmental and behavioural

paediatrics.

The health sector has responded to the needs

of this group through the development and

implementation of the Ottawa Charter (1986). A

public health approach to child abuse prevention

uses the Ottawa Charter to address the whole

spectrum of vulnerabilities displayed by children

and families, instead of trying to identify

individuals using a ‘risk factor’ approach.

The public health approach to child protection

addresses the multiple facets of vulnerability

through the recognition that abuse and

maltreatment is situated within a societal

framework. It are important to ensure that

infants and caregivers are addressed as a

unit, with social and financial assistance and

parenting education forming the basis of the

interventions offered. A family’s drug and

alcohol or mental health problems must be

addressed promptly, particularly as pregnancy

and the immediate period following the birth of

the baby are periods of heightened sensitivity to

the need to adopt healthier lifestyles.

Along with service provision, the development

of healthy communities and building social

capital are essential components of child abuse

prevention. All too often the families and

communities that abused children come from are

socially isolated, and their isolation protects the

abuser rather than the child. Communities must

be supported and encouraged to develop pro-

social environments for children and families.

A public health approach to the prevention

of child abuse builds on the successes of

health promotion, and addresses the needs

of vulnerable communities, families and

children, rather than stigmatising and isolating

individuals. Both medical/forensic and statutory

social work approaches to the care of abused

children are essential to prevent ongoing abuse

and promote recovery. However to prevent child


Working with vulnerable infants

Marie Connolly, Philippa Wells and Jo Field

Infants are one of the most vulnerable groups

of children referred to statutory child welfare

systems, a fact research continues to reinforce.

The average annual rate of child maltreatment

deaths in New Zealand for children under one

year is 4.6 deaths per 100,000, more than three

times higher than the one to four year old age

group, and eight times higher than for children

in the five to 14 year age group (CYF & MSD, 2006;

Connolly & Doolan, 2007). Further, a child’s early

experiences shape almost all aspects of their

development (Harbison, Parnes & Macomber,

2007). Reducing infant abuse and neglect is

therefore critically important when working

with vulnerable infants and their families.

To better understand the needs of vulnerable

infants when they come to the notice of Child,

Youth and Family (CYF) considering in particular

the age and needs of parents, the concerns that

formed the basis of the notification, the needs

of the infants, and the relationships between

family members and interventions, we broadly

examined the case files of 171 infants who

were notified to CYF in the year 1 July 2005 to

30 June 2006.

Because of the particular significance of early

attachment for these vulnerable babies (Knitzer

& Lefkowitz, 2006), it was important that we

paid particular attention to those children in the

sample who were placed in care. We therefore

constructed the sample to evenly represent three

groups:

• infants whose notifications resulted in a care placement

• a group where, on receipt of a referral, it was determined that no further action was required

• children where there was intervention following investigation that did not involve care.

As a whole, this sample over-represents cases

where we take no further action and those

cases where children are taken into care, and

under-represents those circumstances where

there is intervention that does not involve a care

placement.

Understanding the population

From 1 July 2005 to 30 June 2006, a total of

6699 infants were notified to CYF. Seventy-four

percent required further action by the service

and 7% ultimately resulted in a care placement.

Half the babies were under one year, and almost

46% were aged between one and two years when

first notified. A small percentage of the children

were unborn when first notified to CYF (4%).

Perhaps not surprisingly given the population

distribution, 40% of the children were from New

Zealand’s northern regional area, 27% came

from the central region, and the midlands and

southern regions each had 16%.


unavailable to cross-reference with archival

records. In 41% of cases, fathers had been

involved with CYF as children or young men.

This may also be an underestimation as there

were times when the name of the father was not

available on the file.

Families raising these babies appeared small

in structure, consisting mostly of couple

households and a smaller group of sole parent

families. Large multiple adult households were

rare. Although fathers were involved in the

lives of most of the babies, the information on

fathers was underdeveloped

in casework records. In

most cases the families

appeared not to be isolated

and they had strong family

involvement, although this

was often assessed as having

a mixed influence.

A large group of these

families were found to be

already positively connected with support

services when notified, with a smaller group

having less connection with the agencies they

had been referred to. A group remained either

unconnected to support services or actively

refused to take up the services. In the great

majority of cases the families were receiving

income support payments.

Our findings suggest that the 171 babies notified

early for reasons relating to their exposure to

serious adult problems. The cluster of adult

issues associated with these children included

violent or conflicted relationships, alcohol

or drug problems, antisocial behaviour, and

parental mental health concerns. These are

factors known to impact significantly on the

successful care, nurture and development

of infants. The adult caregivers were not

predominantly young people, although a group

Description of the infants within the study sample

The average age at which the 171 infants were

first notified to the service was around six months

of age, and they went on to experience additional

notifications. When notifications for their family

members were also included there was evidence

of a high level of involvement with CYF by these

families. New Zealand Mäori made up 49% of babies

in the sample, 33% were New Zealand European,

and Pacific Island groups constituted 14%.

The notification concerns were found to be

predominantly for family

violence and neglect, and

were usually rated as urgent

or low urgency prior to

investigation. In 21% of

cases the investigation

concluded that harm had not

occurred. Where harm was

substantiated, neglect was

the biggest category reported

comprising 29% of situations. There was little

evidence that notifications were in response to

the infants’ special needs, with 75% of infants

recorded as having no special requirements.

The parental ages were widely distributed with

a mean maternal age of 27 years and a mean

paternal age of 30 years. We found high levels

of antisocial behaviour, alcohol and drug issues,

and mental health problems experienced by

both parents. In 82% of situations the nature of

the adult relationships to which these infants

were exposed were predominantly conflicted or

violent.

A high number of parents had previously been

involved with CYF when they were children or

young people. In 49% of cases, mothers had

been involved with CYF as children or young

people. This is likely to be an underestimate

as the mother’s maiden name was sometimes

The 171 infants were around six months of age when

they were first notified to the service and went on to experience additional

notifications


The records suggested that the parents and

caregivers of infants placed in care were more

often violent towards one another compared to

the other groups. Despite this, there were still

high levels of exposure to conflict and violence

amongst infants who remained with their

families. Antisocial behaviour amongst parents

was a shared characteristic across the three

intervention groups, with particularly high levels

of paternal antisocial behaviour.

The involvement of fathers appeared higher

than we first thought with all the 171 babies.

Particularly for babies for

whom there was no further

action required, there was

a high level of paternal

involvement. The relationship

between the parents or

caregivers of babies in the

‘no further action’ group was

also more positive than other

groups. In addition infants for

whom there was no further

action had significantly

higher levels of positive

family involvement. It may be speculated that

there was some interaction between the higher

level of paternal involvement, less violent

relationships between parents, positive family

support and the assignment of a no further

action status to the case.

Children in the unborn sample

Twenty-seven infants in the sample of 171 were

notified before they were born or on the day

of their birth. A further 61 new cases of babies

notified before their birth were added to make a

comparison group (n=88) with the babies in the

sample who were notified after birth (n=144).

Full statistics, including tests of significance,

are not included here but are available from

the authors. Across many variables there was

of caregivers in this study were teenage parents.

Parental ages were widely dispersed with a

significant group of older parents who had

had a number of children. It is notable that a

large group of parents had themselves been the

subject of child protection concerns when they

were children.

The infants who entered care

Comparisons were made between the three

groups of babies, those who had no further

action taken, those who were placed in

care, and those who had intervention of

a non-care nature. Full

statistics, including tests of

significance, are not included

here but are available from

the authors. We found

that babies placed in care

were generally notified at

a younger age than those

for whom there was no

further action required,

indicating that there were

early concerns about

their wellbeing. When the

notifications for their families were considered

there was an indication that infants placed in

care had families with a greater notification

history with CYF. In addition, when compared

with babies who went on to have a non-care

intervention, infants who were placed had

notifications that were rated as more serious.

Some family characteristics differed significantly

between the intervention groups we compared.

There were higher levels of mental health and/

or substance abuse problems amongst mothers

whose babies were placed in care than for

the other groups. Despite this, even amongst

babies remaining with their parents the rates of

maternal substance abuse and/or mental health

problems remained high.

We found that babies placed in care were

generally notified at a younger age than those for whom there was no further action required, indicating

that there were early concerns about their wellbeing


babies who were notified, with 28% being

recorded as having an intellectual disability

compared to only 4% of mothers of older babies.

Rates of intellectual disability amongst fathers

did not differ between the groups.

Maternal antisocial behaviour also differed

significantly between the comparison groups.

Amongst unborn babies, 64% of mothers

were recorded as having antisocial behaviour

compared to 50% of those

with older babies. In addition

there were high levels of

transience amongst mothers

of notified unborn babies,

with 51% recorded as

transient compared with 30%

of mothers of older babies.

The family situations of

some mothers of unborn

babies were recorded as

better. They experienced

more supportive spousal

relationships and slightly

lower levels of paternal alcohol abuse. The

issues of concern appear to lie around two

predominant maternal characteristics: the

presence of intellectual disability, and a

combination of antisocial behaviour and

transience. The data suggests that there are

probably two distinct groups of mothers

represented in the results, which further

research may be able to confirm.

Discussion

Our findings demonstrate the diversity of

family circumstances and the consistently high

level of need amongst adult caregivers who

were grappling with violent and/or conflicted

relationships, alcohol or drug issues, mental

health problems and antisocial behaviour. A

significant group were not new or immature

little to distinguish the group of infants notified

before birth from those in the larger sample of

children who were notified after birth. Where

differences did emerge, they appeared to reflect

serious concerns about the mother. The number

and severity of notifications was similar between

the two groups, although the age at placement

did vary significantly. The unborn children at

notification moved into care at a mean entry

age of 78.5 days, compared with 295 days for the

larger sample.

There were identical

rates of violence between

spousal couples across the

two groups, however 20%

of couple relationships

associated with the unborn

notified babies were rated

supportive compared to

9% of older babies. Sixteen

percent of relationships

associated with unborn

babies were conflicted,

compared with 44% of couples of older notified

babies. With respect to paternal antisocial

behaviour, there were no significant differences

between the two groups.

Significant differences were apparent between

the two groups when we considered maternal

characteristics. Women bearing children who

were notified before birth were on average

younger than the mothers of babies notified after

birth, with a mean age of 25 years compared to

27 years. There were more women with a CYF

history amongst the group of mothers of unborn

babies, with 71% being known to CYF compared

with 43% of mothers of older babies. There was

no significant difference established with respect

to paternal age.

Rates of intellectual disability were also

significantly higher amongst mothers of unborn

Across many variables there was little to distinguish

the group of infants notified before birth from those in the larger sample

of children who were notified after birth. Where

differences did emerge, they appeared to reflect serious concerns about the mother


in decision-making is important. Although

connecting with hard-to-reach fathers takes time

and energy, it nevertheless provides important

access to the extended paternal family whose

engagement may provide significant protective

support options for the child.

Supervision and monitoring systems can place

a greater emphasis on infants and create more

awareness of their vulnerability. Collaborative

approaches, including case conferencing,

enhance the safety of children and allow us to

mobilise services to wrap around vulnerable

families. Drawing on the strengths and

protective factors within families requires

intense engagement and

support from social workers,

but evidence shows that

it also facilitates greater

change and a stronger safety

net for the child.

Securing safety and belonging

is of critical importance

with vulnerable infants. In

situations where there are

limited opportunities for

family change, the need

for permanency for these

children becomes imperative.

It is important to be mindful

of the child’s timeframe, and their attachment

and developmental needs, to ensure appropriate

permanency decisions are being made and

supported.

In response to our findings, and the findings

of the recent report on increased risk of death

from maltreatment (CYF & MSD, 2006), a set of

initiatives has been introduced across CYF to

raise awareness and strengthen interventions

with respect to work with infants. This includes:

a vulnerable infants’ day in all sites; targeted

education and training sessions for all staff,

parents. The infants were often being cared for

by a group of parents who had had substantive

involvement with CYF over circumstances

pertaining to other children and in many cases

to their own childhoods.

There are a number of limitations of our study

that require us to exercise caution when

interpreting findings. We relied on recorded case

notes which may not reflect a full picture of

the family situation or capture all the practice

interventions. They are also susceptible to data

entry error. Nevertheless, the study does provide

opportunities for policy and practice discussion

about the particular needs of infants notified

to CYF and the support

requirements of their families.

Strengthening practice with vulnerable infants

Four key areas have been

identified as important when

working with infants and

their families: assessment of

infant need; the involvement

of fathers; the supervision

and monitoring of vulnerable

family situations; and the

need to secure safety and

belonging for these babies.

The assessment of infants is critical to

understanding their needs, their attachment

issues, and the impact that adult issues and

behaviour have on their safety and wellbeing.

In-depth information is required to strengthen

our understanding of our work with this group

so we can collectively provide more child-

centred resources and interventions. Interagency

collaboration will enhance this response.

While there may be significant difficulties

in engaging some fathers, involving them

Four key areas have been identified as important

when working with infants and their families:

assessment of infant need; the involvement of

fathers; the supervision and monitoring of vulnerable family situations; and the need to secure safety and belonging for these babies

10SOCIAL WORK NOW: DECEMBER 2007

Dr Marie Connolly is the Chief

Social Worker at the Ministry

of Social Development.

Dr Philippa Wells has

worked in a number of policy

and research roles within

Child, Youth and Family.

She is currently working

in the Ministry of Social

Development’s Centre for Social

Research and Evaluation unit.

Jo Field is the Manager

Professional Practice in

the Ministry of Social

Development’s Office of the

Chief Social Worker.

including content on shaken baby syndrome

and SUDI (Sudden Unexpected Death in Infancy);

a focus on the infants on social workers’

caseloads; and networking meetings with other

professionals and community groups involved

with young children. Enhancements to our

practice framework prompting reflection and

action during the intake and assessment phase

of our work, and strengthened monitoring

of infants at the local level have also been

implemented. Educational opportunities for us to

work with young men in residences and fathers

within the justice system are also being explored.

Our work relating to vulnerable infants signals

the need to focus greater attention on their

care and protection concerns. While it is clearly

important to develop initiatives to strengthen

practice within statutory systems, it is also

important to strengthen collaborative responses

to child abuse by coordinating services across

the spectrum of care. Ultimately, building well

coordinated, culturally responsive systems

that will foster positive family change will be

more likely to impact positively on the lives of

vulnerable children.

R E f E R E n C E s

Child, Youth and family & Ministry of social Development. (2006). Children at increased risk of death from maltreatment and strategies for prevention. Wellington, nZ: Ministry of social Development.

Connolly, M. & Doolan, M. (2007). Lives Cut Short: Child death by maltreatment. Wellington: Office of the Children’s Commissioner.

Harbison, E., Parnes, J., & Macomber, J. (2007). Vulnerable infants and toddlers in four service systems. Children in their Early Years. Brief no 1, september 2007, Washington DC: The Urban Institute.

Knitzer, J. & Lefkowitz, J. (2006). Helping the most vulnerable infants, toddlers, and their families. Pathways to early school success, issue brief no 1. national Centre for Children in Poverty, Columbia University, Mailman school of Public Health.


The role of secure attachment as a protective

factor for vulnerable infantsNicola Atwool

Children begin their lives entirely dependent on

adults for survival. Bowlby (1969) believed that

attachment behaviour was biological in origin,

designed to elicit caring responses from adults.

These responses, however, contribute far more

than simply ensuring infants’ physical survival.

The quality of children’s relationships provides

the framework for the exponential development

and learning that occurs in

the early years. Attachment

experiences lay the

foundation for the child’s

perception of self, others

and the world around them.

Attachment is not limited,

however, to the early

years, and adult capacity to

respond to their infant’s vulnerability is strongly

influenced by their own early experiences.

In this article I outline the significance of

attachment, demonstrating the link with brain

development and resilience, and describing the

way in which children’s vulnerability is influenced

by their attachment experiences. I also describe

the way in which patterns of attachment may

be transmitted from one generation to the next

and the implications of this when assessing

vulnerability in a social work context.

Attachment theory

Attachment theory originated from John

Bowlby’s seminal work in the 1940s and was

further developed by Mary Ainsworth. In recent

years there has been a resurgence of interest,

and a wealth of information is now available.

Attachment research focuses on the relationship

between the infant and the caregiver rather

than the individual

characteristics of either party

(Ainsworth & Bowlby, 1991),

and highlights the infant’s

active participation in the

process. The attachment

figure has a crucial role in

managing anxiety during

the infant’s period of

complete dependency. By developing ‘sensitive

responsiveness,’ or the ability to tune into the

infant and respond appropriately, s/he helps

the infant to form a secure attachment. Once

established, secure attachment provides the

child with a base from which to explore the

world (Ainsworth, 1979).

From her study of mother–infant dyads,

Ainsworth identified three patterns of

attachment: secure, ambivalent and avoidant.

Additional categories have since been identified.

11

Attachment research focuses on the relationship between the infant and the caregiver rather than the

individual characteristics of either party


ability to think about and reflect on relationship

experiences.

Attachment and brain development

More recently, research has focused on the link

between attachment and brain development

furthering understanding of the significance

of attachment. During the first three years of

life, the brain develops rapidly, establishing

neural pathways that allow the more complex

structures of the brain

to come into being

(Schore, 2001). This brain

development is sequential

and use-dependent. Different

areas of the central nervous

system are in the process

of organisation at different

times and disruptions of

experience-dependent

neurochemical signals during

these periods may lead

to major abnormalities or

deficits in neurodevelopment

(Perry, 1997, 1997a). The

role of the environment is crucial and Perry and

Pollard (1998) identify the primary caregiver as

the major provider of the environmental cues

necessary to this development.

Siegel (2001, p. 85) argues that the key element

in attaining complex brain development:

“is the combination of differentiation

(component parts being distinct and well-

developed in their own uniqueness) with

integration (clustering into a functional

whole).”

He argues that human relationships involve

these elements of differentiation and integration

and, by doing so, nurture the development of

these complex states in the brain. Seigel (2001

pp. 85–86) maintains that:

Crittenden (1988) describes an avoidant/

ambivalent pattern and Main, Kaplan and

Cassidy (1985) use the term “disorganised/

disoriented” to describe children in “at-risk”

samples who initially were categorised as secure

because their responses did not fit the other

two categories. There appears to be general

agreement that this fourth category emerges in

high-risk populations and is most likely to occur

in abusive situations.

Internal working models

Bowlby’s concept of internal

working models explains the

long-term impact of early

attachment experiences

(Bowlby 1969, 1973, 1980).

These models are constructed

from the infant’s experience

of interaction and Sroufe

(1988, p. 18) argues that:

“Such models concerning

the availability of others

and, in turn, the self as

worthy or unworthy of

care, provide a basic context for subsequent

transactions with the environment, most

particularly social relationships.”

Internal working models form the basis for the

organisation and understanding of affective

experience (Bretherton, 1985, 1990; Crittenden,

1990; Main et al, 1985), helping to make sense of

new experiences and shaping subjective reality

(Howe, 1995). Internal working models have a

strong propensity for stability, but they are not

rigid templates. There is evidence that during

childhood internal working models may only be

altered in response to changes in relationship

experience. Following the onset of the capacity

for formal operational thinking, internal

working models may be altered through the

Different areas of the central nervous system

are in the process of organisation at different times and disruptions of experience-dependent neurochemical signals during these periods may lead to major

abnormalities or deficits in neurodevelopment

13 SOCIAL WORK NOW: DECEMBER 2007

“Within secure attachments, such self-

organisation may be seen as the gift that

caregivers offer to their children: to enable

the self to achieve differentiation and

integration in acquiring flexible and adaptive

means for self-regulation.”

Schore (2001) emphasises the link between

attachment and the development of self-

regulation. He maintains that exposure to

the primary caregiver’s regulatory capacities

facilitates the infant’s adaptive ability. The brain

is unable to develop without

the ability to approach,

tolerate and incorporate new

experiences. The attachment

behavioural system provides

the framework within which

the child can explore and

manage potentially stressful

new experiences. Schore

argues that when severe

difficulties arise in the attachment relationship,

the brain becomes inefficient at regulating

affective states and coping with stress, and

that this engenders maladaptive infant health.

Stress arises with asynchrony between caregiver

and infant, and sustained stress compromises

development.

Fonagy (2003) adds yet another dimension,

arguing that attachment provides the context

for the infant to develop a sensitivity to self-

states that facilitates the development of

the reflective function. This function is a

vital component of effective interpersonal

communication. Fonagy argues that it is only by

experiencing the primary caregiver’s empathic

expression of the infant’s inferred affective

state that s/he acquires an understanding of his/

her internal state. In the first year, the infant

only has a primary awareness of emotional

states. Through the process of psychobiological

feedback, functional connections are established

that allow the infant to infer the emotional

state of another and to link emotional states

with actions. At the final level of awareness,

the individual is able to reflect on internal

states without the direct link to action. Fonagy

maintains that this facilitates the development

of the interpersonal interpretive mechanism

essential to the ability to function in close

interpersonal relationships. He argues that

it is attachment’s role in facilitating this

development, rather than attachment per se,

that is important.

A complex picture emerges

of attachment relationships

providing the context for

the development of internal

working models that are far

more than cognitive maps.

They incorporate the capacity

for self-regulation, the

ability to identify and reflect

on internal states of self and others, mental

representations of self and others, and strategies

for managing relationship experiences based

on those mental representations. Depending

on the attachment experience, these individual

capacities vary. The degree to which they are

integrated within the individual also varies.

Internal working models and patterns of attachment

Ainsworth’s original three categories of

attachment and later additions represent

internal working models. The secure pattern

provides the context for optimal development.

The consistent sensitive responsiveness of

the primary attachment figure facilitates the

development of an internal working model in

which the self is perceived as worthy, others

are perceived to be reliable and available, and

the environment is experienced as challenging

but manageable with support. The attachment

The attachment figure provides a stable base that facilitates the exploration

of the environment so crucial to early brain

development


experiences of rejection. Affective responses

become deactivated and over-regulated, while

cognitive strategies are amplified. Children

in the avoidant category continue to develop

cognitively and may use play as a means of

diverting attention. The affective component is,

however, not integrated and may be defensively

repressed. Consequently, the dominant approach

is pragmatic problem-solving. Relationships

are not regarded as important, although there

may be underlying anger and resentment.

Control is the dominant strategy. The reflective

function is impaired and

the mental state of others

is likely to be shunned.

Avoidant adolescents present

as sullen and withdrawn

with intermittent outbursts

of rage. Peer relationships

tend to be superficial and

aggressive behaviour may be

triggered in close relationships

because past experience has taught them that

you cannot trust others, especially those close

to you (Allen & Land, 1999). Adults with this

pattern of attachment have been characterised

as dismissive, placing little value on relationships

(Hesse, 1999).

The ambivalent/resistant pattern develops in

response to inconsistent, unreliable and at times

intrusive responses from the attachment figure.

There is uncertainty about the worthiness of the

self. Others are perceived to be unreliable, over-

bearing and insensitive, and the environment

is experienced as unpredictable and chaotic.

Cognitive responses become deactivated because

they are experienced as ineffective due to the

inconsistent response of the caregiver. Affective

responses are amplified and under-regulated

in an attempt to maintain proximity with the

attachment figure. Exploration is inhibited,

increasing the likelihood that cognitive aspects

figure provides a stable base that facilitates

the exploration of the environment so crucial

to early brain development. When faced

with threat, the infant is able to respond with

both affect and cognition in order to elicit

a supportive and timely response. Neural

integration is promoted allowing flexible

and complex networks to develop. The child

achieves balance and mastery is the primary

strategy when confronted with new situations.

The secure child acquires an understanding of

the mind, and has the capacity to reflect on

the internal state of self and

others. Adolescents with a

history of secure attachment

present as confident,

outgoing, and able to access

support when necessary

(Allen & Land, 1999). Adults

with a secure internal

working model have been

characterised as secure and

autonomous (Hesse, 1999).

The two insecure categories represent the

infant’s capacity to adapt to a less than optimal

environment. Bowlby uses the concept of

defensive exclusion to explain the strategies

adopted by the infant in these situations. Some

information is suppressed in order to achieve

the goal of maintaining proximity with an

attachment figure that is not always available or

is actively rejecting.

The avoidant pattern develops in the context of

an unresponsive and rejecting relationship with

the attachment figure. The self is perceived as

unworthy and others are seen to be unavailable

and hurtful. Due to the lack of consistent

support in stressful situations, the environment

is experienced as threatening. The infant has

to become self-reliant at a much earlier stage

and learns to shut down attachment behaviour

in order to protect the self from repeated

The ambivalent/resistant pattern develops in

response to inconsistent, unreliable and at times

intrusive responses from the attachment figure


of brain development may be impaired.

Affective dominance means that self-regulation

is not achieved. Helplessness and resentment

come to characterise children in this category.

Manipulation is the dominant strategy.

There is likely to be a heightened focus on

the internal state of the self, with impaired

capacity to reflect on the internal state of the

other. By adolescence, those with a history of

ambivalent/resistant attachment are likely to be

engaged in intense and explosive relationships

with attachment figures. They may desperately

want relationships with

peers and significant others

but fear rejection and may

drive others away (Allen &

Land, 1999). Adults with this

pattern remain preoccupied

with relationships often

enmeshed in ongoing conflict

(Hesse, 1999).

Children who develop

atypical patterns have most often been exposed

to neglect and abuse. They face the daunting

task of maintaining proximity to a parent

who is the source of threat. The avoidant and

ambivalent/resistant strategies are adaptive to

the extent that they enable the child to maintain

the proximity of the primary caregiver, thereby

accessing support in dealing with stressful

situations. Although there is some disagreement

about the extent to which the atypical patterns

are adaptive, there is agreement that some

children do not develop consistent adaptive

strategies.

The primary caregivers of children in this

category are described as frightening or

frightened (Main et al, 1985). In abusive

situations, the self is perceived to be unworthy

and others are perceived as frightening and

dangerous. When the primary caregiver is

frightened, the self is perceived to be unworthy

and others are seen to be helpless. In both

situations the environment is experienced

as dangerous and chaotic. Hyper-arousal

characterises these children, impairing cognitive

development. Affective responses are likely

to dominate and there are deeply conflicting

emotions. The lack of consistent response and

patterned experience significantly impacts

on development. The infant is fearful and

reactive. Exploration is inhibited and children

in this category may not develop a capacity for

symbolic play.

Some children in this

group may later develop

compulsive compliance,

compulsive caregiving or

controlling behaviour.

Survival is the dominant

strategy. Their capacity to

reflect on their own internal

state is limited and they

may lack the ability to identify feeling states.

They are hyper-vigilant of caregiver cues and

the internal state of others. Their reflective

capacity is, however, significantly impaired by

this lack of balance. Research indicates that

significant problems in childhood and later life

are most frequently linked with this pattern.

By adolescence, significantly increased rates of

psychopathology and violent crime have been

found in longitudinal studies of infants classified

as disorganised in infancy (Allen, Hauser &

Bormen-Spurrell, 1996; Carlson, 1998; Lyons-

Ruth, 1996; Rosenstein & Horowitz, 1996; van

Ijzendoorn, 1997). In adulthood, this pattern

has been described as unresolved/disorganised

(Hesse, 1999).

Attachment and resilience

Longitudinal research has demonstrated that

children ‘at risk’ do not all fare badly (Werner

By adolescence, significantly increased

rates of psychopathology and violent crime have

been found in longitudinal studies of infants classified as disorganised in infancy


The avoidant and ambivalent patterns are

adaptive and demonstrate a degree of resilience

in less than optimal circumstances, allowing

children to manage relationships and emotions.

They will, however, find it difficult to access

external support because their expectation is

that adults are unavailable or unreliable. Those

children with a disorganised attachment pattern

are the most vulnerable, lacking a coherent

strategy for managing relationships, feelings

or experience. This pattern develops in the

context of trauma and adversity. Subsequent

negative experiences only serve to confirm

their experience of themselves as unworthy,

adults as hurtful, and the world as a dangerous

place. It is almost impossible

to access support in such

circumstances.

Continuity of attachment patterns

There is evidence of both

continuity and discontinuity

in patterns of attachment

over time. Some have argued

that the lack of continuity

indicates that the relevance of attachment to

later development has been overstated (Lewis,

Feiring & Rosenthal, 2000). The small number

of studies and differences in a number of

variables, including time over which stability has

been assessed, sample size, socio-demographic

characteristics, age range and the degree to

which environmental change was measured,

further complicates the picture. It is hardly

surprising that the results are not uniform. Of

perhaps greater significance is that to a large

extent the results confirm Bowlby’s emphasis on

the all-important role of real world experiences

and his assertion that internal working models

are open to change (Waters, Hamilton &

Weinfield et al, 2000). Despite the different

& Smith, 1982) and similar findings have

resulted from research exploring biological,

developmental and environmental risk factors

(Garmezy, 1994; Garmezy, Masten & Tellegren,

1984; Haggerty, Sherrod, Garmezy & Rutter,

1994; Rutter, 1981). Resilient children have been

found to have an easy temperament, high self-

esteem, an internal locus of control and a sense

of autonomy. They have a supportive family

environment and a supportive person or agency

outside the family (Brown & Rhodes, 1991;

Compas, 1987; Garmezy, 1994).

More recently, an international research project

across ten communities in seven different

countries has identified the importance of

cultural connection (Ungar,

2003, 2005). In New Zealand

we tend to think of culture as

relevant for minority groups

but it is also important to

think about the cultural

aspects of mainstream

children’s experience,

especially in terms of the

extent to which different

cultural groups create a sense of belonging.

The most resilient children and young people

have access to all four components (individual

characteristics, family support, community

support and cultural belonging) but any one can

make a difference. It is clear that resilience is

not an isolated individual characteristic and it

is difficult to see how any of these protective

factors could be acquired outside the context of

secure and consistent attachment.

A secure internal working model encompasses

all of the factors that contribute to resilience.

In the face of adversity, the secure child

has internal resources and an expectation

that significant adults will be available and

responsive. This allows them to elicit support.

Those children with a disorganised attachment

pattern are the most vulnerable, lacking a coherent strategy for

managing relationships, feelings or experience


results, there appears to be a growing consensus

that the relationship between early attachment

experiences and later development is complex

(Thompson, 1999). Internal working models are

constantly revised and updated in the light of

new experiences. Although there is a propensity

for stability, research clearly demonstrates that

significant change can occur.

Intergenerational transmission of attachment patterns

Processes by which

attachment patterns may

be transmitted across

generations have been

identified (Fraiberg, Adelson

& Shapiro, 1980; Main

& Goldwyn, 1984; Ricks,

1985) and a link between

unresolved attachment issues

in parents and the abuse

of children established (Call, 1984; Fraiberg et

al, 1980; Main & Goldwyn, 1984; Schmidt &

Eldridge, 1986). Main et al. (1985) investigated

the relationship between security of attachment

during infancy and both the child’s and the

parent’s mental representations of attachment

five years later. They found strong stability in

the child’s apparent security on reunion with the

mother over the five-year period and a weaker

but significant stability with the father. The

adult attachment interview confirmed that the

parent’s representation of their history shaped

the way in which the infant was conceptualised

and treated.

Main et al suggest that because parents’ internal

working models shape their response to the

infant, parents with insecure attachment

histories may restrict or reorganise attachment-

relevant information about their child’s

behaviour in terms of their own working

models. The infant’s internal working model

then develops in response to these experiences

and in this way inter-generational transmission

occurs. Negative outcomes are not inevitable.

With access to coherent, organised information

about their own attachment, parents who have

experienced rejection or trauma, including

losing attachment figures, are able to experience

security in adulthood and

foster secure attachment in

their children.

Conclusion

Secure attachment acts as

a protective factor for both

infants and parents. I have

focused on the long-term

impact for children but secure

attachment also protects

parents when they are tired

and stressed, enabling them

to empathise with a distressed

child and resist the impulse to lash out. An

understanding of the dynamics of attachment is

central to understanding vulnerability because

the focus is on the two-way interaction between

infants and their parents.

Attachment provides the key to success for

parents, caregivers and children, providing the

glue that holds families together and makes

them safe (Atwool, 2005). Early intervention

when there are difficulties has a significantly

greater chance of success. The arrival of a

child may provide a window of opportunity,

stimulating parents with difficulties to engage

in the work necessary to address attachment

issues arising from earlier negative experience.

Referral to specialists for an attachment

assessment is strongly recommended in cases

where social workers are intervening in families

with vulnerable infants. Such assessments

can provide information about the quality of

With access to coherent, organised information

about their own attachment, parents who

have experienced rejection or trauma, including losing attachment figures, are able

to experience security in adulthood and foster secure attachment in their children


Carlson, E. A. (1998). A prospective longitudinal study of attachment disorganisation/disorientation. Child Development 69 (4), 1107-1128.

Compas, B. (1987). Coping with stress during childhood and adolescence. Psychological Bulletin, 101, 392-403.

Crittenden, P. (1988). Relationships at risk. In J. Belsky & T. nezworski (Eds.), Clinical implications of attachment (pp. 136-176). Hillsdale, nJ: Lawrence Erlbaum and Associates.

Crittenden, P. (1990). Internal representational models of attachment relationships. Infant Mental Health Journal, 11, 259-277.

fonagy, P. (2003). The development of psychopathology from infancy to adulthood: The mysterious unfolding of disturbance. Infant Mental Health Journal, 24 (3), 212-239.

fraiberg, s., Adelson, E., & shapiro, V. (1980). Ghosts in the nursery: A psychoanalytical approach to the problems of impaired infant-mother relationships. In s. fraiberg (Ed.), Clinical studies in infant mental health. The first year of life (pp. 164-196). London: Tavistock.

Garmezy, n. (1994). Reflections and commentary on risk, resilience, and development. In R. J. Haggerty, L. R. sherrod, n. Garmezy, & M. Rutter (Eds.), Stress, risk and resilience in children and adolescents. Processes, mechanisms and interventions (pp. 1-19). Cambridge: Cambridge University Press.

Garmezy, n,. Masten, A. s., & Tellegren, A. (1984). The study of stress and competence in children: A building block for developmental psychopathology. Child Development, 55, 97-111.

George, C., & solomon, J. (1989). Internal working models of caregiving and security of attachment at age six. Infant Mental Health Journal, 10, 222-237.

Gore, s., & Eckenrode, J. (1994). Context and process in research on risk and resilience. In R. J. Haggerty, L. R. sherrod, n. Garmezy, & M. Rutter (Eds.), Stress, risk and resilience in children and adolescents. Processes, mechanisms and interventions (pp. 19-64). Cambridge: Cambridge University Press.

Hesse, E. (1999). The adult attachment interview. In J. Cassidy & P. R. shaver (Eds.), Handbook of Attachment (pp. 395-433). new York: Guilford Press.

Howe, D. (1995). Attachment theory for social work practice. London: Macmillan Press.

Lewis, M., feiring, C. & Rosenthal, s. (2000). Attachment over time. Child Development, 71 (3), 707-720.

attachment relationships and the capability of

the parent to engage in the work necessary to

address difficulties.

R E f E R E n C E s

Ainsworth, M. (1979). Infant-mother attachment. American Psychologist, 34, 932-937.

Ainsworth, M., & Bowlby, J. (1991). An ethological approach to personality development. American Psychologist, 46, 333-341.

Allen, J. P., Hauser, s. T. & Borman-spurrell, E. (1996). Attachment theory as a framework for understanding sequelae of severe adolescent psychopathology: An eleven-year follow-up study. Journal of Consulting and Clinical Psychology, 64 (2), 256-263.

Allen, J. P. & Land, D. (1999). Attachment in Adolescence. In J. Cassidy & P. R. shaver (Eds.), Handbook of Attachment (pp. 319-334). new York: Guilford Press.

Atwool, n. R. (2005). Working with adults who are parenting. In M. nash, R. Munford, & K. O’Donghue (Eds.), Social Work Theories in Action (pp. 223-238). London: Jessica Kingsley.

Bowlby, J. (1969). Attachment and loss: Vol. 1. Attachment. new York: Basic Books.

Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. new York: Basic Books.

Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss, sadness and depression. new York: Basic Books.

Bretherton, I. (1985). Attachment theory: Retrospect and prospect. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research (pp. 3-35). Monograph of the society for Research in Child Development, 50, (1 & 2, serial no. 209).

Bretherton, I. (1990). Communication patterns, internal working models, and the intergenerational transmission of attachment relationships. Infant Mental Health Journal, 11, 237-251.

Brown, W. K., & Rhodes, W. A. (1991). factors that promote invulnerability and resiliency in at-risk children. In W. K. Brown & W. A. Rhodes (Eds.), Why some children succeed despite the odds (pp. 171-177). new York: Praeger.

Call, J. D. (1984). Child abuse and neglect in infancy: sources of hostility within the parent-infant dyad and disorders of attachment in infancy. Child Abuse & Neglect, 8, 185-202.


Lyons-Ruth, K. (1996). Attachment relationships among children with aggressive behavior problems: The role of disorganised early attachment patterns. Journal of Consulting and Clinical Psychology, 64 (1), 64-73.

Main, M., & Goldwyn, R. (1984). Predicting rejection of her infant from mother’s representation of her own experience: Implications for the abused-abusing intergenerational cycle. Child Abuse & Neglect, 8, 203-217.

Main, M., Kaplan, n., & Cassidy, J. (1985). security in infancy, childhood and adulthood: A move to the level of representation. In I. Bretherton & E. Waters (Eds.), Growing points of attachment theory and research (pp. 66-104). Monograph of the society for Research in Child Development, 50, (1 & 2, serial no. 209).

Matas, L., Arend, R. A., & sroufe, L. A. (1978). Continuity of adaptation in the second year: The relationship between quality of attachment and later competence. Child Development, 47, 547-556.

Perry, B. (1997). Incubated in terror: neurodevelopmental factors in the "cycle of violence". In J. D. Osofsky (Ed.), Children in a Violent Society (pp. 124-149). new York: The Guilford Press.

Perry, B. (1997a). Memories of fear. In J. Goodwin & R. Attias (Eds.), Images of the body in trauma. new York: Basic Books.

Perry, B. D. & Pollard, R. (1998). Homeostasis, stress, trauma and adaptation. A neurodevelopmental view of childhood trauma. Child and Adolescent Psychiatric Clinics of North America, 7 (1), 33-51.

Ricks, M. (1985). The social transmission of parental behaviour: attachment across generations. In I. Bretherton, & E. Waters (Eds.), Growing points of attachment theory and research, (pp. 211-227). Monograph of the society for research in Child Development, 50, (1 & 2, serial no. 209).

Rosenstein, D. s. & Horowitz, H. A. (1996). Adolescent attachment and psychopathology. Journal of Consulting and Clinical Psychology, 64 (2), 244-253.

Rutter, M. (1981). stress, coping and development: some issues and some questions. Journal of Child Psychology and Psychiatry, 22, 323-356.

Rutter, M. (1994). stress research: Accomplishments and tasks ahead. In R. J. Haggerty, L. R. sherrod, n. Garmezy, & M. Rutter (Eds.), Stress, risk and resilience in children and adolescents. Processes, mechanisms and interventions (pp. 354-386). Cambridge: Cambridge University Press.

Rutter, M., & Rutter, M. (1993). Developing minds. Challenge and continuity across the life span, new York: Basic Books.

schmidt, E., & Eldridge, A. (1986). The attachment relationship and child maltreatment. Infant Mental Health Journal, 7(4), 264-273.

schore, A.n. (2001). Effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Infant Mental Health Journal, 22 (1-2), 7-66.

siegel, D. J. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships, "mindsight", and neural integration. Infant Mental Health Journal, 22 (1-2), 67-94.

sroufe, L. A. (1988). The role of infant-caregiver attachment in development. In J. Belsky & T. nezworski (Eds.), Clinical implications of attachment (pp. 3-17). Hillsdale, nJ: Lawrence Erlbaum and Associates.

Thompson, R. A. (1999). Early attachment and later development. In J. Cassidy and P. shaver (Eds.), Handbook of Attachment (pp. 265-286). new York: Guilford.

Tiet, Q. Q., Bird, H. A., Davies, M., Hoven, C., Cohen, P., Jensen, P. s. & Goodman, s. (1998). Adverse life events and resilience. Journal of American Academy of Child and Adolescent Psychiatry, 37 (11), 1191-1200.

Ungar, M. (2001). The social construction of resilience among ‘problem’ youth in out-of-home placement: A study of health-enhancing deviance. Child and Youth Care Forum, 30 (3), 137-154.

Ungar, M. (2003). Methodological and contextual challenges researching childhood resilience: An international collaboration to develop a mixed method design to investigate health-related phenomena in at-risk child populations. www.resilienceproject.org

Ungar, M. (2005). Introduction: Resilience across cultures and contexts. In M. Ungar (Ed), Handbook for working with children and youth (pp. xv-xxxix). Thousand Oaks, CA: sage.

van Ijzendoorn, M. H. (1997). Attachment, emergent morality, and aggression: Toward a developmental socioemotional model of antisocial behavior. International Journal of Behavioral Development 21 (4), 703-727.

van Ijzendoorn, M. H. & sagi, A. (1999). Cross-cultural patterns of attachment. In J. Cassidy & P. R. shaver (Eds.), Handbook of Attachment (pp. 713-734). new York: Guilford Press.


Waters, E., Hamilton, C. E. & Weinfield, n. s. (2000). The stability of attachment security from infancy to adolescence and early adulthood: General introduction. Child Development, 71 (3), 678-683.

Werner, E. E., & smith, R. s. (1982). Vulnerable, but invincible. new York: McGraw-Hill.

Wyman, P. A., Cowen, E. L., Work, W. C., Hoyt-Myers, l., Magnus, K. B. & fagan, D. B. (1999). Caregiving and developmental factors differentiating young at-risk urban children showing resilient versus stress-affected outcomes: A replication and extension. Child Development, 70 (3), 645-659.

Nicola Atwool is a Principal

Advisor in the Office of the

Children’s Commissioner. Prior

to taking up this position in

2006, she was a Senior Lecturer

in social work at the University

of Otago and worked with the

Children’s Issues Centre. Before

that Nicola was employed for

nearly 20 years in a variety

of roles by what is now Child,

Youth and Family.


Strengthening our engagement with families and understanding practice depth

Megan Chapman and Jo Field

Statutory child protection work is often viewed

as the sharp end of social work practice, located

in a turbulent environment characterised by

continuous change, complex case dynamics

and scarce resources. Working in such a

demanding context can be fraught with anxiety,

tension and stress for both practitioners and

managers. It requires workers to be resilient

and resourceful in order to maintain a practice

approach that empowers vulnerable families

to utilise their strengths and resources, and to

make safe decisions for their children. Critical

to this process is the way practitioners engage

with vulnerable families to create relationships

and conditions that facilitate change in human

systems.

This article describes the importance of how

we approach and respond to children, young

people and families, and explains the importance

of practice depth. Organisational factors can

impact on practice depth and we therefore

pay particular attention to this. Strengths-

based practice and professional supervision

provide opportunities to mitigate against these

influences, supporting practice that is engaging,

respectful and focused on the safety of children

and young people.

From child rescue to strengths-based practice

Child protection practice has historically

oscillated between family preservation and

“child rescue” models. Extreme expression

of these positions can mean excessive state

intervention at the child rescue end of the

continuum and minimisation of the safety issues

at the other. According to Weil (cited in Patti,

2000, p. 483):

“As service systems have grown, the child

rescue approach and the community-based

service approach have co-existed, and in

some periods, the pendulum of social policy

has swung forcefully one way or the other,

with the child rescue approach usually

prevailing.”

Whilst the pendulum has swung, it is

nevertheless a delicate balance to manage risk

in the context of family support. A key factor

disturbing this delicate balance has arguably

been the reviewing of child deaths (Reder,

Duncan & Gray, 1993), which writers have

suggested creates an overly cautious, defensive

practice approach (Connolly & Doolan, 2007).

Defensive practice is elicited by very strong

anxiety factors, which can be a powerful and

21


individuals/families/groups in order to increase

resilience, coping skills and the achievement

of their goals (Berg and Kelly, 1997; de Shazer,

1985; Scott and O’Neil, 1996). The approach

focuses on the abilities, hopes and dreams of

clients and accords them expertise in their

own lives. It seeks to shift the power dynamic

away from a relationship based on ‘expert

professional/helpless client’ to one that creates

a partnership of working together to achieve

goals. The focus is on

“solution finding” (Berg and

Kelly, 1997) rather than

problem-solving.

“Safety organised practice”

Strengths-based work is

manifested in the “solution-

building” approach (Berg

and Kelly, 1997) to child

protection work. Berg and

Kelly suggest that social

workers, like all helping

professions, have been

trained in the traditional problem-solving

approach based on the medical model. They

argue that this locks workers into being ‘the

expert’, with a heavy emphasis on professional

assessment and intervention. This dependence

on assessing the problem and analysing the

causes has the potential to keep workers and

the family stuck in an unhelpful deficit cycle.

Strengths-based practice puts less emphasis

on the nature and severity of the problem

and more focus on solutions – sometimes

querying whether problems and solutions have

to be connected. This presents a significant

challenge to the fundamental thinking of the

problem-solving approach. Strengths-based

practitioners argue that the clients are the

‘experts’ in their own lives and therefore focus

controlling dynamic for workers who are not

safely contained by competent professional

supervision. A defensive practice culture can

unhelpfully reinforce a “child rescue” approach

where children are too easily removed from

their families for fear of blame from the

organisation and/or the media if anything goes

wrong. Despite the rarity of child deaths, such

tragic events nevertheless rest at the heart of

practitioner fear (Ferguson, 2004, p. 122):

“The paradox is that

social workers’ fears and

anxieties have multiplied

at a time when the actual

phenomenon of child

death in child protection

is such an extremely

rare experience that

only a tiny fraction of

professionals will ever

encounter it.”

The heavily interventionist

response that can be driven

by these anxieties can also

lead to the critical alienation of the child from

their family and is not conducive to a safe,

timely return home.

Other factors that have been identified as

contributing to a more defensive practice

philosophy are: the media (Ferguson, 2004;

Mansell, 2006), the prevailing political climate

and social policies (Munro, 2002), and budgetary

constraints and the availability of resources

(Field, 2004). Invariably the development of

non-defensive practice philosophy will also be

influenced by the individual practitioner’s own

value base, knowledge, skills and competencies.

In recent years, the move to strengths-based

practice principles has emphasised the need to

promote strengths and address vulnerabilities of

In recent years the move to strengths-based practice principles has emphasised the need to promote strengths and address vulnerabilities of individuals/families/

groups in order to increase resilience, coping skills and the achievement of

their goals


These themes are emphasised in the practice

frameworks introduced into Child, Youth and

Family practice in 2005 (Connolly, 2007). Practice

frameworks integrate empirical research,

social work theory, ethical principles and

cultural strengths in practical ways that help

practitioners use knowledge to inform their

work (Connolly & Ward, 2008). The care and

protection practice framework incorporates

three perspectives: child-centred; family-led

and culturally responsive; and strengths and

evidence-based practice.

It also includes key messages

from the literature relating

to child protection work.

The youth justice practice

framework includes “justice

and accountability focused”

as an additional perspective.

These frameworks provide

opportunities for workers to

understand and deepen their

practice knowledge while

reflecting on their approach

and decision-making.

Understanding practice depth

The importance of developing practice depth

is not a new idea. It is usually associated

with descriptions of reflective practice: sound

decision-making, characterised by reflective

analysis and demonstration of comprehensive

professional knowledge and skill. The literature

often refers to in-depth practice being promoted

and supported by quality supervision.

However, in recent years, writers have noted the

challenges of promoting practice depth within

pressured child protection work environments

(Ferguson, 2004; Munro, 2002; Scott, 2006).

Indeed, in what he identifies as “conveyor-belt

practice”, Ferguson (2004, p. 212) argues:

on building solutions as a way to move families

forward.

Because of their clear mandate to support child

safety, the notion of clients being ‘experts’ in

their own lives creates a potential dilemma for

child protection practitioners trying to work

in a strengths-based way. Statutory decision-

making about child protection often involves

using authoritative social work knowledge and

expert opinions from other professionals. This

can create challenge for the worker regarding

their understanding of

‘expertise’. It is a tension that

needs careful reflection and

supervision to achieve the

appropriate balance.

In the “signs of safety”

approach (Turnell and

Edwards, 1999) the focus of

strengths is reframed into

how they can be used by

the family or practitioner

to increase the safety of

children. The level of danger and risk of harm

to a child is compared to the strengths and

protective factors in the family’s situation but

safety of the child or children remains the key

focus – what Turnell now refers to as “safety

organised practice”. This approach emphasises

the need to build safety from protective factors.

Tools used to support this practice (Turnell and

Edwards, 1997) have been designed to be used

and shared with the family. This shifts the use

of assessment resources from the professional

‘expert’ domain toward a process of engagement

and transparency with the family, supporting

relationship building, and the generation of

hope and conditions for change. From this,

families are empowered to make safe decisions

about their children.

This shifts the use of assessment resources from the professional

‘expert’ domain toward a process of engagement and transparency with the family, supporting

relationship building, and the generation of hope and

conditions for change

23


The third level of practice we identify is

reflective practice. This is characterised

by processes of critical reflection, strong

professional decision-making, and an emphasis

on engagement with and responsiveness to

children, young people and their families. A

key feature of reflective practice is access to

supervision that encourages critical reflection

on issues.

We would argue that practice systems under

pressure are more likely to be susceptible to

less in-depth reflective practice. We would

also suggest that even when pressure abates,

conveyor-belt and pragmatic practice potentially

have lasting consequences as a culture of less

in-depth practice becomes entrenched and

difficult to change.

Challenges to in-depth practice

Within pressured organisational settings there

are times when conveyor-belt or pragmatic

practice may seem unavoidable, for example

during periods of increased notification rates,

when sites are responding to high levels of

unallocated cases, or when there are significant

“Pressure to get cases ‘through the system’

creates a situation where attention, time and

resources are diverted from doing in-depth,

needs-driven work with children and families

in ways which can promote child safety,

welfare and healing.”

Drawing upon Ferguson’s work we now explore

levels of practice depth from conveyor-belt

practice to the kind of reflective practice that

characterises in-depth work (figure 1). Within

this conceptualisation, conveyor-belt practice

is event-driven (i.e. notification) and front-

end focused. It is characterised by the need

to respond primarily to efficiency drivers and

getting families through the system. Meeting

targets and moving quickly to case closure is

considered critically important.

The second level of practice we identify as

pragmatic practice. Here practice is characterised

by general compliance with policy and practice

guidelines, and moderate engagement with

family and other agencies (that is considered

sufficient to efficiently manage the work), with

a focus on case management and administrative

supervision.

Figure 1: Understanding practice depth

Conveyor-belt practice (Ferguson, 2004), characterised by: responsiveness to efficiency

drivers; getting cases through the system; meeting targets; speedy casework resolution;

and general compliance with policy and practice guidelines.

Pragmatic practice, characterised by: compliance with policy and practice guidelines;

moderate engagement with family and other agencies; efficient throughput of work; case

management; and supervision.

Reflective practice, characterised by: critical reflection on issues; principled, quality

practice decision-making and interventions; depth of analysis; engagement with families

and responsiveness to their needs while maintaining a child protection focus; mobilising

supports and resources; and access to critical supervision.

pr

ac

tic

e d

ep

th


numbers of staff vacancies. Having time to

critically reflect upon aspects of an intervention

can seem a luxury for a busy practitioner. There

are also occasions when moving quickly toward

an appropriate referral to a community support

agency is exactly the right thing to do. Not all

interventions require the same level of intensity,

nor do they all require processes of in-depth

reflection.

When practice is occurring

at the conveyor-belt or

pragmatic level, however, it

is important for workers to

have the capacity to pause

and take a deeper look at

a case when needed. For

example, in situations of

several intakes over a short

period of time, it is important

to look at the particular

safety needs of the child and

the support needs of the

family. While previous intakes may have been

dealt with appropriately in an efficient way,

continued referrals about a child or family may

require more reflective and critical analysis. In

this regard, Child, Youth and Family’s dangerous

situations policy (2002) states that where three

or more notifications have been received for a

child within a period of 12 months:

“this is sometimes an indication that a

pattern has emerged that requires a closer

evaluation including, where appropriate, a

review by the practice leader or a referral to

the dangerous situations team.”

Hence, professional judgement is required to

determine what level of practice depth may be

required at different times during the life of

a case. The initial assessment of a notification

requires that the social worker understand at

a deeper level what issues confront the family,

and their ability to provide safety and security

for their child. Similarly when new information

is received, for example there is a new partner

in the home or the family has a crisis, a more

in-depth approach may be needed to ensure that

the safety risk has not increased for the child.

It is also important to understand the

relationship between practice depth and

processes of engagement with families in child

protection work. There will

be times when a situation

requires only one contact

with a family. In these cases,

as with more enduring and/or

intense encounters, practice

needs to be respectfully

engaging, informative and

clear with regard to what

the family might expect and

where they may seek future

support.

What can we do about “risk anxiety”?

Hearing of cases involving the non-accidental

injury of infants and other vulnerable children

can create fear or anxiety amongst social

work practitioners, particularly in the child

protection field. Practitioners may wonder

whether a similar incident could happen on

their caseload, or whether they will miss a vital

piece of information or assess the level of risk

incorrectly. They may think of all the cases they

are responsible for and believe that they all have

the potential to result in a negative outcome.

Ferguson (2004, p. 117) refers to this fear as “risk

anxiety” which he believes is a relatively recent

shift in thinking:

“Up to the 1970s under simple modernity

professionals had an inherent belief in

the capacity of their expertise to enable

them to protect children in time. Even if in

While previous intakes may have been dealt with

appropriately in an efficient way, continued referrals

about a child or family may require more reflective and

critical analysis


practice they sometimes failed to do this, the

sequestration of child death both expressed

and bolstered their faith in the science of

child protection. The dominant belief among

social workers today is that no matter

how effectively the child protection system

operates it cannot guarantee safety for

children.”

Strengths-based supervision and reflective

practice can create more supportive practice

environments and alleviate a good deal of this

fear and anxiety (Morrison, 2001). Field (2004)

argues that a primary goal for all supervisors is to

maintain a safe supervision practice regime that

responds to the individual needs of practitioners.

Social work staff will respond to their work in

unique ways. An important

aspect of the supervisor’s role

is to understand the particular

needs of staff, to identify

when risk anxiety is hindering

positive practice with families,

and to influence and support

social workers as they manage

the complex but necessary

dynamics of child safety,

family support, and family

decision-making.

Regular supervision is a key component in

promoting greater practice depth and the

lessening of risk anxiety. Child, Youth and

Family has a supervision policy that provides

mechanisms for safeguarding the work

undertaken with children and families, and

provides opportunities to encourage critical

reflection of practice that in turn creates

confidence in assessment and decision-making.

Munro (2002, p. 154) reinforces the role of

supervision as vital to ensuring a reflective,

open-minded approach to working with and

assessing family situations:

“Not only does [supervision] provide the

intellectual challenges to help practitioners

stand back and be critical of their work but

it also provides the secure setting in which

they can face this emotionally challenging

task.”

Supervision is therefore a process which

supports the worker, challenges them to ensure

a respectful and competent approach, contains

their anxiety, and moderates the practice depth.

In pressured systems, the ability to create

supportive supervisory environments can be

challenging for organisations managing complex

child protection situations. Developing capacity-

building, peer group learning environments

for staff; utilising practice leadership strengths

across the wider system; and

creating structured processes

that strategically target areas

of concern are all important

to strengthen practice.

Conclusion

Building practice depth

requires a whole-of-

organisation approach that

acknowledges the inevitable

challenges of contemporary child protection

work and works across a range of systems to

enhance in-depth service delivery. Within Child,

Youth and Family, the practice frameworks

introduced in 2005 have provided a foundation

for more engaging quality practice with

children, young people and their families. The

recent enhancements of the vulnerable infant

practice triggers are a further way of promoting

more reflective practice as workers assess and

respond to vulnerable children.

The challenge for any organisation is to ensure

that workers continue to apply the practice

Strengths-based supervision and reflective practice can

create more supportive practice environments and alleviate a good deal of this

fear and anxiety


framework principles and explicitly consider the

practice triggers in their practice. This promotes

the adoption of a respectful and skilful practice

approach that adds practice depth, even in

the context of a pressured work environment.

Practice frameworks offer an antidote when

practice cultures lacking in depth become

entrenched.

Strengths-based practice

provides workers with an

approach that respects

and values the strengths

and resources that families

can use to empower

themselves and create

lasting change. While the

organisational environment

can either support or hinder

strengths-based practice

by constraining practice

depth, less in-depth practice

does not mean that the worker abandons a

respectful, engaging approach to the family.

Strengths-based practice can still be applied at

all levels of practice, even when high levels of

casework intensity are not required.

It can be easy to dismiss reflective practice as

being too time consuming, labour intensive and

impossible within a challenging organisational

environment where the meeting of targets

and speedy casework resolution is promoted.

Reflective practice, however, need not take

impossible amounts of time. Critical reflection

of practice can occur whenever casework is

discussed. It can become the way things are

done, rather than being seen as an added

pressure. In reality we spend a considerable

amount of time talking about casework.

Maximising these conversations to increase

reflective opportunity creates more reflexive

environments that are possible even in the

busiest of offices. Familiarity with practice

triggers and their application can also be

effective in guiding immediate decision-making.

In developing the practice depth

conceptualisation in figure 1, we aimed to

illuminate the levels of practice available to

workers when they engage with children, young

people and their families. Greater understanding

of these levels, and the style

of practice they promote,

helps us to more fully

appreciate how practice

cultures develop and what

this might mean for the

delivery of services.

R E f E R E n C E s

Berg, I. & Kelly, s. (1997). Building Solutions in Child Protective Services. new York: WW norton and Co.

Child, Youth and family (2000). Violence Prevention Code of Practice (Dangerous Situations Policy) Wellington: new Zealand.

Child, Youth and family (2007). Vulnerable Infant Practice Triggers. Wellington: new Zealand.

Connolly, M. (2007). Practice frameworks: Conceptual maps to guide interventions in child welfare. British Journal of Social Work, 37 (5) 825-837.

Connolly, M. & Doolan, M. (2007). Lives cut short: Child death by maltreatment. Wellington: Office of the Children’s Commissioner.

Connolly, M. & Ward, T. (2008). Morals, rights and practice in the human services: Effective and fair decision-making in health, social care and criminal justice. London: Jessica Kingsley Publishers.

de shazer, s. (1985). Keys to Solution in Brief Therapy. new York: W.W. norton & Co.

ferguson, H. (2004). Protecting Children in Time: Child Abuse, Child Protection and the Consequences of Modernity. new York: Palgrave.

field, J. (2004). Strengthening professional practice: The role of practice manager in New Zealand Child, Youth and Family. Thesis submitted in partial fulfilment of Master of social Work, Massey University, Palmerston north.

Strengths-based practice provides workers with an

approach that respects and values the strengths and

resources that families can use to empower themselves and create lasting change


Mansell, J. (2006). The underlying instability in statutory child protection: Understanding the system dynamics driving risk assurance levels. Social Policy Journal of New Zealand, 28, 97-132.

Morrison, T. (2001). Staff supervision in social care. Brighton, UK: Pavilion.

Munro, E. (2002). Effective Child Protection. London: sage.

Patti, R. (2000). The Handbook of Social Welfare Management. London: sage.

Reder, P., Duncan, s. & Gray, M. (1993). Beyond Blame. London: Routledge.

scott, D. (2006). Towards a public health model of child protection in Australia. Communities, Families and Children in Australia, 1 (1) 9-16.

scott, D. & O’neil, D. (1996). Beyond Child Rescue. Australia: Allen and Unwin.

Turnell, A. & Edwards, s. (1999). Signs of Safety: A Solution and Safety Oriented Approach to Child Protection. new York: norton.

Megan Chapman is an Advisor

in the Ministry of Social


Chief Social Worker. Her

interest areas are children in

care, vulnerable infants and

disability.

Jo Field is the Manager

Professional Practice in

the Ministry of Social


Chief Social Worker.


Post-traumatic stress disorder and borderline personality disorder traits in the child

welfare populationEmily Cooney and Kirsten Louden-Bell

This article focuses on two conditions – post-

traumatic stress disorder (PTSD) and traits of

borderline personality disorder (BPD) – that are

often associated with exposure to abuse and

neglect (e.g. Katerndahl, Burge & Kellogg, 2005),

one of which (PTSD) is more prevalent in child

welfare and juvenile justice populations (CYF,

2002). Composite case examples are used to

illustrate the ways in which youth with these

problems may present to Child, Youth & Family

(CYF). The article reviews the diagnostic criteria

for each condition, briefly discusses some of the

issues professionals encounter when working

with young people presenting with these

conditions, and provides recommendations for

obtaining treatment.

Borderline personality disorder traits

Jessica is a 14-year-old Pakeha girl whose arms

(particularly her left) and legs have extensive

and varied scarring. Her file reports that she has

made four suicide attempts; three by panadol

overdose and one by asphyxiation. She speaks

quietly in a flat tone about the events that led

to her involvement with CYF, describing how

her mother (later diagnosed with schizophrenia)

used to beat her regularly when she was little for

soiling, as well as recounting the sexual abuse

she experienced from male relatives.

Jessica has had multiple placement breakdowns.

Typically, she has formed rapid and close

attachments with her caregivers in the first few

days. Caregivers have initially been impressed

by her level of maturity, her fortitude, and her

resilience, and have been keen to help her solve

the life problems that have led to her placement

with them. Caregivers have often disclosed

personal details of their own lives to her. A

honeymoon period follows which lasts between

six and eight weeks, in which the caregiver

remains supportive of Jessica despite problems

cropping up at school, with peers, or with

members of the public.

The history in her file describes Jessica’s life

as a series of seemingly “unrelenting crises”

(Linehan, 1993). In her last placement, Jessica

was assaulted while waiting to be picked up from

the movies after getting into an argument with

another group of young people. The following

week, she absconded from the placement to

attend a party one night, slept with her best

30

friend’s boyfriend, and was distraught and

overcome with guilt and remorse when the friend

cut off all contact with her. She bombarded the

friend with desperate apologies in the form of

multiple texts, phone calls, bebo postings and

cards. When the friend relented and agreed

to meet her for coffee (after Jessica threatened

suicide), Jessica didn’t show up, and subsequently

seemed disinterested in repairing the friendship.

Notes describe Jessica as

having unpredictable bursts

of rage, in which she has

assaulted residence staff,

community caregivers,

and other young people.

Frequently staff have noted

that there has been no

obvious reason for the angry

outbursts, and Jessica herself

reports finding her emotions

confusing and overwhelming.

She notes that “I can be feeling fine one minute,

and then someone says something and I’m so

f…..d off I want to kill them”. She has said that

she’d rather not have any feelings, is afraid of

them, and doesn’t see any good in them. Jessica

reports feeling numb a lot of the time, which she

typically prefers. However, she reports that she

will occasionally cut in order to “feel something”,

at points when she is experiencing numbness and

emptiness and finding the experience intolerable.

Definition and criteria

Jessica presents with many of the symptoms of

BPD. This is a condition that is characterised

by emotional instability. By definition, a

personality disorder is an enduring pattern

of behaviour, thinking and feeling over

an extended period of time, and therefore

diagnosing young people with this condition is

controversial. In addition, many of its traits are

similar to the features of adolescence in general.

However, even if a constellation of behaviour

might be common or normal in certain groups of

people, it is arguably still reasonable to identify

it as problematic or pathological if it creates

significant problems for the person or people

around them. Furthermore, when working with

young people who present with BPD traits, it can

be useful to consider the theory and principles

of effective treatments for adults with this

condition. Even if it would be

premature to diagnose

the young person with BPD,

considering what has worked

for adults and theories

about the emergence of

such problems can help

professionals find empathy for

the young person and guide

decisions about management

of their behaviour.

The diagnostic criteria of this condition (APA,

2000) are:

• frantic efforts to avoid real or imagined abandonment

• a pattern of unstable and intense relationships where the person ricochets between admiring and despising the other person

• identity disturbance, lack of a stable sense of self

• impulsivity in at least two areas (e.g. unprotected promiscuous sex, bingeing, alcohol and other drug abuse)

• recurrent suicidal behaviour, threats, or self-harm

• intense and rapid fluctuations in emotions

• chronic feelings of emptiness

• intense and inappropriate anger/difficulty controlling anger

• transient paranoia that is stress-related, extreme dissociation.

By definition, a personality disorder is an enduring pattern of behaviour,

thinking and feeling over an extended period of time,

and therefore diagnosing young people with this

condition is controversial


Management

This amalgam of problems poses a management

challenge to most systems of care. If a young

person is presenting with self-harm or suicidal

behaviour (i.e. threats, reports of thoughts

about suicide or attempts) or serious symptoms

of emotional disturbance, a referral to their

local child and adolescent mental health services

is recommended. It is typically useful to copy

any written referral to the GP that the person

is currently registered with (even if they have

not seen their doctor for a long time or have

only seen their doctor once).

The reason for this is that the

GP is (ideally) the point of

continuity and initial contact

regarding any health problems

that the young person is

experiencing.

For many notification issues,

the role of CYF is often seen

to be discrete, time-limited,

and task-focused. While there

are costs and benefits to this

approach, and there are a range of views on

whether a young person requires a longer period

of monitoring by a statutory agency, if CYF

cannot undertake an extended monitoring role,

ensuring that the person’s primary health care

provider has enough information to monitor

effectively is essential. This also means that

when there is a transfer of health care, the new

practitioner will receive a record of the earlier

concerns, and therefore be better placed to

monitor this and broker ongoing treatment.

Frequently, working with young people with

these problems can be confusing, burdensome,

and very stressful for the professionals involved.

A prominent theory regarding the emergence of

BPD highlights the interplay between the person

and their social environment in the development

of this disorder (Linehan, 1993). This theory

(the biosocial model of BPD) states that BPD is

caused by the transaction over time between an

emotionally sensitive and reactive child, and an

environment that (intentionally or otherwise)

invalidates that child’s experiences.

Invalidation in this context refers to any

action or communication in response to the

child’s behaviour that indicates to the child

that their feelings, actions, wants, needs,

thoughts, or sensations are unimportant, non-

existent, inappropriate or wrong. From this

perspective, abuse and

neglect constitute extreme

forms of invalidation.

Frequently removal from

abusive or neglectful

situations doesn’t completely

solve the problems of these

young people. Furthermore,

invalidation exists on a

continuum and the majority

of people experience

frequent invalidation

without developing BPD.

The biosocial theory provides a possible

explanation for why problems can persist

after a young person has been placed in a

safe environment. The theory states that the

repeated interactions between an emotionally

vulnerable young person and invalidating

responses by people in their immediate

environment are what set the scene for

the development of BPD. Furthermore, the

theory emphasises the bi-directionality of

these influences; the young person’s extreme

emotional responses, unpredictability and

impulsivity can exhaust the resources of the

people around them. This makes their caregivers

less responsive to emotional expression, and

raises the risk of further invalidation, more

emotional arousal and less resilience.

the biosocial model of BPD states that BPD is caused by

the transaction over time between an emotionally

sensitive and reactive child, and an environment that

(intentionally or otherwise) invalidates that child’s

experiences


The environment becomes relatively immune to

low-level emotional outbursts, which leads to

an escalating pattern of increasing emotional

explosions in order to obtain any type of helpful

or caring response from the people around

them. People are increasingly likely to feel

manipulated, angry and tired of such responses,

and therefore more likely to respond selectively

to outbursts that are so intense and frightening

that they are seen to require some effort to

contain or manage them. With such problems,

it is often useful to bear in mind that all human

actions are shaped by their context (an example

is a fortnightly pay packet;

few people would continue

to go to work if they were

not getting paid), and that

often we are not fully aware

of the factors that are

influencing our behaviour.

Accordingly, there is every

likelihood that young people

who are confused and afraid

of the strength of their

feelings are largely unaware

of how much their emotional behaviour is

influenced by other people’s responses. If the

biosocial theory applies to the experience of

such young people, then two very helpful things

that professionals can do are (1) to validate

the person’s experience in any way that is

accurate and respectful of both the person and

the professional, and (2) to pay very careful

and precise attention to the factors in the

environment that may be shaping or supporting

problematic behaviour, and to selectively shape

up and reinforce more skilful behaviour. For

caregivers and social workers to have any

chance of maintaining such a dual-pronged

approach, support and acknowledgement of the

difficulties and burnout risks associated with

working with emotionally reactive young people

is essential.

Post-traumatic stress disorder

Jaydon is a nine-year-old boy of Maori, Pakeha/

New Zealand European, and Cook Island Maori

ethnicity. He is currently placed with his aunt

and her female partner after he was uplifted

from his mother’s house at the age of six years

following concerns regarding physical abuse and

neglect, along with exposure to family violence

between his mother and her partner. The

notification to CYF was made by police following

a call out which led to the partner’s arrest for

assault, and Jaydon’s mother’s admission to

hospital for surgery following

multiple skull and facial

fractures and a closed head

injury.

Jaydon is a quiet boy who

often seems somewhat dazed

and disconnected from his

surroundings. However he

is also very watchful, and

becomes extremely anxious at

any sign of disagreement or

raised voices between his aunt

and her partner. Previously, if

they ended up arguing in his presence he would

retreat to a corner of the room and become

‘frozen’; his gaze would become unfocused, he

would look terrified, and his body would be

tense and rigid. In the first 18 months after he

came to live with them, he suffered frequent

night terrors. His play tended to be solitary, and

characterised by repetitious and violent scripts.

These would involve taking two (sometimes three)

figurines from an action set he had been given

and enacting an argument between two of them.

This would culminate in a fight in which the

larger action doll would beat up the other one

who was then put in the back of an ‘ambulance’

(a dump truck) and put to bed. Occasionally the

third action doll would intervene and vanquish

the larger doll.

there is every likelihood that young people who are confused and afraid of the strength of their feelings are largely unaware of

how much their emotional behaviour is influenced by other people’s responses


His initial year at his new school was tumultuous;

he hit another pupil twice, hit his teacher once,

and was stood down on three occasions following

these incidents. These outbursts were very

unpredictable and it was difficult to identify in

retrospect what had prompted them. In his first

year Jaydon also became extremely distressed

when he saw men dressed in fluorescent high-

visibility safety vests, although he is now much

calmer in the presence of these cues. His

caregivers have been very gentle with him, while

remaining unwavering in their insistence that

he refrain from violent behaviour. They have

encouraged him to take his own pace at putting

himself in situations which he finds frightening

but which are objectively safe.

Definition and criteria

PTSD is a condition that is characterised by

avoidance, increased physiological arousal,

and re-experiencing following exposure to an

event which involved the threat or occurrence

of death or serious injury or physical integrity

(APA, 2000). The traumatised person does not

have to have directly experienced the event;

it is possible to present with PTSD as a result

of witnessing an event involving the above

characteristics. The person’s response has

to have involved intense fear, helplessness

or horror (APA, 2000). In children, this may

manifest as agitation or disorganised behaviour.

According to the Diagnostic and statistical

manual of mental disorders (DPA, 2000),

re-experiencing emerges in one or more of the

following five ways:

• recurrent and distressing memories of the event (in children this may emerge as repetitive play involving themes associated with the trauma)

• recurrent nightmares

• acting or feeling as if the trauma were recurring/reliving the experience

• intense subjective distress when exposed to reminders/cues associated with the trauma

• intense physiological reactivity when exposed to reminders/cues associated with the trauma.

Avoidance and numbing is evidenced by three or

more of the following:

• efforts to avoid thoughts, feelings or talking about the trauma

• efforts to avoid traumatic cues, i.e. people, places or activities that might prompt memories of the trauma

• inability to recall a significant aspect of the trauma

• diminished interest or participation in important activities

• feeling detached or cut off from other people

• restricted emotional range, i.e. blunting/numbing – “emotional anaesthesia” (APA, 2000, p. 464)

• sense of foreshortened future.

Symptoms of increased arousal are outlined

below and must be greater than baseline levels

of physiological arousal before exposure to

trauma:

• difficulty sleeping, i.e. interrupted sleep, difficulties getting to sleep

• irritability/angry outbursts

• reduced concentration

• hyper-vigilance, i.e. unusually responsive to any indication of threat in the environment

• exaggerated startle response.

These symptoms must have occurred for longer

than a month and be significantly interfering

with the person’s life in order to meet criteria

for PTSD. A file review of children and young

people within CYF indicated that approximately

6% met criteria for PTSD (CYF, 2002).


Management

The two best-evidenced treatments for adults

with PTSD are prolonged exposure and eye-

movement desensitisation and reprocessing

(EMDR). Prolonged exposure is a cognitive-

behavioural therapy that includes a very

systematic and paced/graduated series of

exercises designed to get the person to

experience all the thoughts, contexts, feelings

and sensations associated with the trauma they

have been avoiding. The

treatment seems to work

by allowing the person’s

body and mind to gradually

habituate or accustom itself

to the cues associated with

activation of the traumatic

response so they no longer

experience intense distress

when faced with reminders of

the trauma.

It takes between 12 and 16 weeks for treatment

to occur and it has a relatively good success

rate. Between 40% and 90% of people no

longer meet criteria for PTSD after nine to 12

sessions (SAMHSA, 2003; Schnurr et al, 2007).

After completing cognitive-behavioural therapy

incorporating prolonged exposure modified

for children and adolescents, 92% of young

participants no longer met criteria for PTSD. This

compared with the wait list control participants,

of whom 58% still suffered from PTSD (Smith et

al, 2007).

In terms of readiness to undertake treatment

for PTSD, it is important to ensure that the

person has enough skills in dealing with and

experiencing painful emotions to be able to

tolerate the treatment. If they are engaging

in self-harm or suicidal behaviour, there is

little evidence to suggest that they have

enough resilience and behavioural control to

be able to participate in treatment that will

involve exposure to further emotional arousal.

Accordingly, any treatment for PTSD with such

individuals will have to focus on providing them

with skills to manage their emotions and stop

suicidal and self-harm behaviour first.

The second consideration relates to willingness to

see the treatment through, as stopping treatment

before the person experiences an improvement

in their distress may give them an experience of

failure, and sensitise them to

the traumatic cues further,

i.e. make the problem worse

rather than better. For

this, informed consent and

therapeutic engagement is

extremely important.

When referring children and

young people to counsellors

registered by ACC to provide

treatment for abuse or

trauma, it is helpful for social workers to assist

family members or caregivers in determining (1)

whether the practitioner adheres to a treatment

that has evidence of working, (2) how the

practitioner monitors progress and assesses

outcome, and (3) what the practitioner’s initial

treatment goals will be for a traumatised person

who is actively self-harming or suicidal. PTSD

often co-occurs with other mental disorders,

such as depression, and substance abuse. When

the co-morbidity contributes to a more complex

presentation, it may be more appropriate for

the young person to be seen within a multi-

disciplinary team rather than by an individual

clinician.

Conclusion

Young people within the CYF environment are

likely to have experienced elevated levels of

exposure to the risk factors associated with

After completing cognitive-behavioural therapy

incorporating prolonged exposure modified for

children and adolescents, 92% of young participants

no longer met criteria for PTSD


developing PTSD or BPD traits. Therefore it is

important that social workers are aware of these

conditions and how best to seek appropriate

treatment for them. The provision of support for

social workers in the recognition, management

and accessing of services for these complex

conditions is also essential.

R E f E R E n C E s

APA (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: American Psychiatric Association.

Child, Youth and family (2002). Working with children and young people with mental health problems and their families and whanau: A guide for Child, Youth, and Family staff. Child, Youth and family: Wellington.

Katerndahl, D., Burge, s., & Kellogg, n (2005). Predictors of development of adult psychopathology in female victims of childhood sexual abuse. Journal of Nervous and Mental Disease, 193, 258-264.

Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. new York: Guilford.

sAMHsA (2003). http://www.modelprograms.samhsa.gov/pdfs/model/PE-PTsD.pdf

schnurr, P. P., friedman, M. J., Engel, C. C., foa, E. B., shea, M. T., Chow, B. K., Resick, P. A., Thurston, V., Orsillo, s. M., Haug, R., Turner, C., & Bernardy, n. (2007). Cognitive behavioral therapy for post-traumatic stress disorder in women: A randomized controlled trial. Journal of the American Medical Association, 297, 820-830.

smith, P., Yule, W., Perrin, s., Tranah, T., Dalgleish, T., & Clark, D. M. (2007). Cognitive-behavioral therapy for PTsD in children and adolescents: A preliminary randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 46, 1051-1061.

Dr Emily Cooney works as

a research co-ordinator and

clinical psychologist at the Kari

Centre, a child and adolescent

mental health service in

Auckland. She has a strong

interest in effective treatments

for suicidal and self-harm

behaviour that are acceptable

and useful to adolescents and

families in Aotearoa/

New Zealand.

Kirsten Louden-Bell is a clinical

psychologist who has worked

in adult and child mental

health in both inpatient and

outpatient settings. She has

been involved with the Toward

Wellbeing Suicide Consultation

and Monitoring Programme

for the past five years and has

been the Clinical Manager of

the programme for the last

two.


Book reviews

Helping Mothers Move Forward

– A workbook to help provide

assessment and support to the safe

carers of children who have been

sexually abused

By Lynda Regan

Published in 2006 by Russell House Publishing,

Dorset

ISBN 978-1-903855-87-4, 1-903855-87-X

Reviewed by Michele Olds

This is an easy to follow workbook for people

working with the mothers/safe carers of children

who have been sexually abused. It provides

workers with the tools to provide support,

information, and understanding to the safe

carers.

The author, Lynda Regan, has worked with

children and families in a variety of settings for

over 18 years. She has worked with mothers of

children who have been sexually abused, in both

the investigative and recovery stages of their

individual experiences.

The workbook is in five parts, each of which

contains several exercises.

Part one of the workbook, ‘Setting the scene’, is

about preparing the worker for engaging with

the mother. It includes understanding impacts

and reactions to unexpected and shocking news;

looking at a framework for assessment; and

drawing up a working agreement.

Part two, ‘Techniques to promote engagement

and participation’, is about understanding the

mother/safe carer’s standpoint and creating a

supportive environment.

In part three, ‘Defining the issues’, Regan looks

at providing a framework for the mother/safe

carer to understand about sexual abuse. It is “a

way of developing a mother’s knowledge in this

area, and then considering how she applies this

in order to keep her children safe in the future”.

In part four, ‘Making it personal’, the worker is

aided to analyse work done to date and identify

any gaps or areas that need to be revisited.

Part five, ‘The future’, looks at what additional

issues are important to consider and what

additional information is needed, and offers a

framework for issues of safe care, especially if

the family wants to consider reunification.

The workbook “aims to assess and offer therapy

and support to the primary carer so…

• they can cope with the reality of what has happened to their child, and the impact on their child and family;

• they can support their child to deal with the aftermath of sexual abuse; and

• they can become a safer carer in the future”.

Each part of the workbook builds on the one

before. It provides in-depth information for

anyone working with mothers/safe carers. While


the focus is on sexual abuse, the material could

be adapted for other areas of abuse and neglect.

I would highly recommend this book for any

social work practitioner, particularly for those

who have limited experience of working with

families regarding child sexual abuse.

Michele Olds is a Specialist Interviewer in Child, Youth and

Family’s Wellington service centre.

Top Ten Tips for Placing Children in

Permanent Families

By Hedi Argent

Published in 2006 by the British Association for

Adopting and Fostering, London

ISBN 978-1-90-905664-05-4, 1-90-5664-05-2

Reviewed by Carla IJssennagger

“This is the book I always wished there was, and

finally decided to write it myself” is the opening

sentence Hedi uses and I am glad she wrote this

book!

The author has been a practitioner for nearly 40

years and has drawn from her years of experience

in writing this practical guide. Each chapter in the

book deals with one of the ten tips. The subjects

are explored in a logical way when you are

dealing with placing children in care.

Each chapter has quotes from children, birth

parents or foster parents that complement its

particular subject. The following is a quote by an

eight year old:

“Me and my sister and brother, we live with

our foster mum and dad. They haven’t got no

other kids so they love us like special. We’re

staying here for ever ’cause even grown ups

can have families. We’ve got two families, we

live with one and the other’s like a spare.”

Every chapter also has several points a

practitioner can use to trigger their thinking

when placing a child with a permanent family.

Where appropriate, it refers to relevant research

and a list for further reading is published at the

end of each chapter.

I took particular interest in tip number seven

which is: “agree a support plan for this

placement”, as well as the following sentence

that caught my eye: “but we have no right to

expect the resulting placements to be better

than the support we give”. So true but hard

to remember when dealing with a disrupted

placement. This chapter deals with the fact that

no person and thus no foster parent or child is

the same. Supporting children in that particular

placement is a tailored and skilled task. One

foster parent might be happy with a bi-monthly

visit from the social worker, while another needs

to have a weekly phone call. What is seen as

support by one foster parent might be seen as

‘checking on’ by a different foster parent.

The author highlights several elements in

supporting the placement; one of those is

making speedy referrals to experts as and when

required. She advises that at the start of the

permanent placement, an agreement has to

be reached on how to access services and how

these will be funded to ensure a quick response

when support is needed.

I also enjoyed reading chapter five, which deals

with the transition process from one placement

to another. As a professional I have always had

mixed feelings around the support I could offer

a child while in transition. It can feel awful to

remove a child from a foster family where the

child has lived for a while and appears to have

bonded well with the caregivers.

One of the pieces of advice the author gives

is to make an introduction plan that has to be

negotiated and agreed to by all parties, ideally

chaired by an independent person.


Top Ten Tips for Placing Children in Permanent

Families is an easy to read book that has a huge

range of practical tips and advice when placing

children in permanent care. I really enjoyed

reading this book and use it in my current job as

the supervisor of a permanency team as a tool

to reflect or to develop some of the areas of our

work.

I look forward to the future titles in the same

series, one of which will deal with finding

families and managing contact.

Carla IJssennagger is a Supervisor in the Permanency Team at

Child, Youth and Family’s Waitemata service centre.

Health of Looked After Children

and Young People

By Kathy Dunnett, with Sharon White, Janet

Butterfield and Imelda Callowhill (Eds)

Published in 2006 by Russell House Publishing,

Dorset

ISBN 978-1-903855-83-6, 1-90-3855-83-7

Reviewed by Lorell Webster

This book raises the key question of why children

in care need a different response to their health

needs than other children. It highlights those life

experiences that can adversely affect the health

and wellbeing of children including neglect,

abuse or poor parenting prior to children

coming into care. It also draws attention to the

fragmented nature of services once children are

in care and the difficulty in coordinating these

amongst professionals who are often transient in

children’s lives.

The stated aim of this book is “to provide the

reader with a deeper understanding of the

difficulties of providing healthcare to a highly

vulnerable group of children and young people.”

The book also provides the reader with clear

evidence of innovation and success in meeting

the health needs of looked after children in the

U.K. The timing of this book coincides perfectly

with current developments to improve access

to health services for children in care in New

Zealand. It is invaluable in raising awareness and

increasing the knowledge base of all of us who

are engaged at any level with children in care.

It states the importance of making the health

of children in care “everyone’s responsibility”

providing inspiration for what might be achieved

when professional boundaries are crossed in

working for improved outcomes for children.

The book is clearly written and accessible. I was

captured by the reflections of children at the

very beginning, and I enjoyed reading about the

journey taken by dedicated professionals in their

quest to improve the health of children in care.

The chapters are written by individual health

and welfare practitioners, and the reader can

dip into a chapter of specific interest. Mental

health, sexual health and substance abuse are

holistic health issues that resonate with many

of us who are involved with children in care in

New Zealand. These are all comprehensively

covered, along with issues such as nutrition

and the complex needs of asylum-seeking

children. The involvement of caregivers in

contributing to children’s health and wellbeing,

as described in this book, was enlightening. It

was encouraging to read that the efforts of the

book’s contributors were assisted by national

government policies to support and improve the

health of children in care.

The book left me feeling energised, motivated

and also privileged to be involved in improving

the health of children in care in New Zealand.

Lorell Webster is a Care Specialist based in Child, Youth and

Family’s Nelson office.


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vulnerability and child protection

working with vulnerable infants

the role of secure attachment as a protective factor

strengthening engagement with families and understanding practice depth

post-traumatic stress and borderline personality disorders in the child welfare population

Documents

Working with vulnerable infants