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Does the SACCS Assessment Process contribute to the ‘Recovery’ of Traumatised Children in the area of Attachment?
2006
Submitted in partial fulfilment for an
MA in Therapeutic Child Care,
Department of Community Studies
This paper explores an assessment process that is in existence in an independent childcare company that looks after traumatised children. In particular it considers how well it works as a tool to assist carers to think about and understand what relevance ‘Attachment Theory’ (Bowlby 1969) has to caring for children who have been scarred by their earliest relationships. It goes on to explore whether a good assessment leads to a good plan for thoughtful intervention in a child’s day to day care, so that healthier patterns of relating to others may be possible.
The literature in the area of assessment is explored and a sample of existing assessments critiqued. Attachment Theory is examined for what it can offer to workers who live with and care for our most vulnerable children. With the use of a small-scale survey questioning staff who work with the assessment process, and my participant-observation in three assessments, I have considered what we can learn not only about the assessment under scrutiny but about the value of assessment in general, particularly in the field of Attachment.
I would like to thank Linnet McMahon, Deborah Best, Paul Cain and Teresa Howard for their unfailing care and support during the last two years, it has been amazing. Also my fellow students Debbie, Derek, Di, Gary, Jenny, John, Joycelyn, Jude, Karol, Katrina, Marc, Maria, Pat, Rosie, Sue, and Tony, thank you for your ‘sharing’. I’ve learnt so much from being with you and will always treasure our time together, you are wonderful people. Also, a huge welcome to our two Thursday TCC babies!
A special thanks to my good friend Denise Snell who kindly looked after me every Wednesday evening on my way down to Reading, it meant a lot.
To my colleagues at SACCS, Lesley Stephens, Lee Ridgley, Niall Kelly and Steve Elliott who have had to hold the fort while I’ve been away in Reading, and who have been interested, helpful and tolerated my pre-occupation. To Rob McKay who encouraged me to go and believed I could do it and Patrick Tomlinson for support and advice. To all the Managers and their teams for helping me with the questionnaires and especially the three teams who welcomed me into their assessments, this study is down to you guys. A special to the children at SACCS who always have so much to teach us and to the adults who continue to care.
To my family, Charlie, George, Molly, Ben and Charley-rose, thank you for putting up with my ‘disappearing act', with a promise to be back soon! A special mention to Charlie, who encouraged me to keep going at a point where I wanted to give up, and for his technical support. Also to my sister Corinne Taylor, and my best friends Fiona Gordon and Janice Betteridge who are always there when I need them and who have promised to take me out as soon as this is over!
Finally to my mom (posthumously) and dad with whom I’ve spent the whole journey of this dissertation, thank you and I love you both.
This paper is a study of part of the assessment process that is currently in operation within SACCS, an independent childcare company for whom I work as Deputy Director of Practice. In particular, it evaluates whether the process is effective in identifying the pattern of attachment a child has developed and whether this identification is effective in informing a treatment programme.
Adrian Ward (2001: 9) defined ‘assessment for treatment’ as ‘the process of making sense of current available experience to help you have some idea of what is going on in your interactions with the child in order to modify, interrupt, emphasise or even ignore certain aspects of the dynamic’. He continues, ‘you can have assessment without treatment but you certainly can’t have treatment without assessment.’
This is of interest to me because I have worked for SACCS for almost ten years, and in the first seven there was no corporate way of assessing children for treatment. Each of our nine homes invented their own methods of assessment, whether relying on one person’s opinion, or using assessments found in useful books. As a manager, in collaboration with a therapist, I used two assessments, one from Ziegler (2001) to help to determine a child’s level of attachment disorder, and the other from Illsley-Clarke and Dawson (1989) to determine emotional stage of development. These two assessments worked very well for the children I looked after and I was apprehensive when the new corporate assessment came into being.
The SACCS Recovery Assessment is a relatively new tool for the company and since its advent has played a major part in the overall care of the children. It is a time consuming and therefore expensive tool to use. Each assessment involves a number of professionals preparing for, taking part in and following up the assessment for each child. It is also a major consumer of administrative staff’s time. In my capacity as Deputy Director of Practice, until recently I was involved in 36 assessments per year. In addition to attending the meetings I also have assessment papers to monitor, and treatment plans to proof read and agree. I estimate that each assessment constitutes about 4 hours of my time. Others involved in the process spend maybe up to 8 hours per assessment. A conservative estimate of total time taken up for each assessment is approximately 70 hours. As the process consumes so much of my time and others’ I am keen to know whether the time spent is effective.
I have a particular interest in the area of ‘Attachment’. Bowlby (1998) believed that parents had the most powerful influence on a child’s development and that the child’s internal working model (op cit 1969) is set in the earliest months of their life, and confirmed as a child continues to grow. This model shapes whether children view themselves as loveable, whether carers are believed to be trustworthy and whether the world is perceived to be a pleasant place. ‘These early attachment experiences become internalised as core beliefs and anticipatory images that influence later perceptions, emotions and reactions to others.’(Levy and Orleans 1998: 46 cited in the SACCS Assessment Document 2004). The internal working model is very resistant to change but can with appropriate experiences become modified.
In examining the assessment process in the area of attachment I evaluate whether it enables the workers to think about a child’s attachment history and how it has affected her current beliefs and therefore relationships with others. Further, I investigate whether it helps the carers to provide the child with an appropriate alternative experience that will bring about a more healthy attachment pattern for the future.
It is my impression that this section often attracts one of the lowest scores at a first SACCS Recovery Assessment and that at later assessments, the graph shows less growth. This may indicate that attachment is a key issue for traumatised children, and that to alter established patterns of attachment is a slow process. If so, it is essential that Recovery Assessment leads to thoughtful interventions necessary for change.
I begin my investigation in chapter two, with a literature review of attachment theory, looking at how it has developed and changed over the years since Bowlby first formulated the basic philosophy of his theory between 1940 to1950.
I also review other methods of assessment for treatment, looking at their strengths and weaknesses. I examine and evaluate both ‘The Needs Assessment’ devised by Dockar-Drysdale (1968) and pioneered by The Mulberry Bush School and The Cotswold Community and the assessment used by The Caldecott Community created by Bradley and Hardwick (1999). Also, Adrian Ward’s ideas discussed at a Therapeutic Childcare Study Day at Reading University (2004) have been used to help form the basis for my enquiry. The Boxall Profile (1998) which was originally developed to support the work in nurture groups in Inner London schools in the 70’s and 80’s, and has now replaced Dockar-Drysdale’s Needs Assessment at the Mulberry Bush School also comes under scrutiny. Other assessments examined include the Framework for Assessment of Children in Need and their Families. (2000)
Finally in this chapter I look at assessments specifically aimed at measuring attachment. This begins with the Ainsworth Strange Situation Test (1978) and includes Narrative Stems, Adult Attachment Interviews (George, Kaplan and Main 1985) and Zeigler’s Attachment Assessment (2000).
Having looked closely at the literature I formulate in my conclusion whether the SACCS Recovery Assessment has anything to be offered from my examination.
I proceed in chapter three to expand on the use of a small-scale survey, canvassing workers by questionnaire on the effectiveness of the process and also elaborate on my participant-observation of three assessments. I explain how the data already collected by the company will be reviewed and also discuss in full the ethical considerations of the study.
It will be necessary to put the study into context by explaining what SACCS is and the type of work undertaken within, and also to outline the Assessment Process under inspection. This will be set out in chapter four.
In chapters five, six, seven and eight I lay out the results of my investigation, reflect on the study as a whole and my part in it, and draw my conclusions. Implications for the SACCS Recovery Assessment will be discussed and I will make recommendations for improvement. As assessment for treatment in therapeutic childcare is relatively unexplored, this study in its conclusions should offer something that goes beyond SACCS.
The literature review makes up a large part of my study and I intend to evaluate it in three sections, 1) attachment theory, 2) assessment, 3) assessment of attachment.
Attachment has been defined as ‘an affection bond between two individuals that endures through space and time and serves to join them emotionally’ (Kennell, 1976 cited in Fahlberg 1979: 5)
Fahlberg goes on to say that ‘The bond that a child develops to the person who cares for him in his earliest years is the foundation of his future psychological, physical, and cognitive development and for his future relationships with others.’
This bond develops through behaviours from both the baby and the parent, an infant cannot survive without a care provider, and its earliest behaviour is designed to capture the care. ‘The baby’s behaviour and the parent’s instinctive nurturing responses meet in the newborn period to fuel the growth of attachment between them.’ (Brazelton and Cramer 1991:45)
Howe et al (1999:17) cite Bruner (1983), Trevarthen (1979) and George (1966) in their description of the mother-baby interaction. ‘They are expressive from birth, with the capacity for much reciprocal, emotionally synchronised behaviour with their mothers. In turn, most mothers seem highly alert and sensitive to their baby’s physical and emotional states.’
Winnicott was one of the first people to point out the interdependence of the mother and baby, ‘A baby cannot exist alone but is essentially part of a relationship.’ (1987 cited in Brazelton and Cramer 1991: xv) Further ‘If you set out to describe a baby you will find you are describing a baby and someone.’ (op cit)
Attachment behaviour begins with ‘neonatal crying, sucking, clinging and orientation,….only a few weeks later, smiling and babbling and some months later still, crawling and walking.’ (Bowlby: 1971:319) ‘They (attachment behaviours) persist through childhood and adult life, extending to partners, work colleagues and friends, and even god.’ (McMahon 2001:53) It is an entirely normal response to ensure survival.
Attachment theory is derived mainly from the joint work of John Bowlby and Mary Ainsworth (Ainsworth and Bowlby 1991). Through the formulation of his beliefs, Bowlby changed the thinking about a child’s tie to its mother and how, through separation, deprivation and bereavement the tie could be disrupted or disturbed. Ainsworth developed methods to test Bowlby’s theories and also helped to expand the theory into new directions. Freud and other psychoanalytical thinkers of their time influenced both in their early careers. James Robertson also played an intrinsic part in the development of the theory, initially through his thorough observation of hospitalised and institutionalised children separated from their parents. Later he went on to make the moving film ‘A Two-Year-Old Goes to Hospital (Robertson, 1953a 1953b; Robertson & Bowlby 1952). This film helped to shape the fate of hospitalised children throughout the Western World.
John Bowlby’s genius was to bring together an array of scientific disciplines and philosophical outlooks…..Out of this inspirational blend of psychology and ethnology, evolutionary theory and biology, systems thinking and cognitive science, the personal and the interpersonal, emerged the concept of attachment, which in the hands of modern-day theorists is more than just another approach to children’s socio-emotional development: it is the theory that subsumes and integrates all others.
( Howe et al. 1999)
Findings in Bowlby’s early studies convinced him that ‘when deprived of maternal care, a child’s development is almost always retarded – physically, intellectually, and socially – and that symptoms of physical and mental illness may appear.’(Bowlby: 1953: 21)
Alongside this he also found that even short periods of time away from their mothers caused babies to act in a particular way, this could be broken down into 3 phases, protest, grief and mourning, and detachment. He felt that his findings in both of these studies were linked in someway. Working with Ainsworth and Robertson, using close, systematic observations of parent-child interactions, a model for studying the attachment process was developed.
Attachment behaviour is activated in children whenever they feel distressed or insecure and their need is to gain close proximity with their main caregiver. When the caregiver is lost to the child through any form of separation, the child becomes anxious and in need of soothing. This behaviour is intrinsic to a child’s survival. A prolonged or repeated separation of the main caregiver causes the child distress. Absence could be psychological as well as physical.
As a child develops there is an increased need to explore his surroundings and move out into the world, yet being in connection with the main caregiver remains important. ‘This balance changes as a function of the child’s experiences, developmental growth, and family environment’ (James 1994: 29) If the parent provides a secure base that the child can return to when distressed, then the child is free to explore his environment. Farnfield (1998:78) writes ‘secure dependence is thus essential for healthy independence and there is a positive correlation between secure attachment and self-esteem: if I am loved then I must be loveable’.
Ainsworth identified three situations in which attachment behaviour could be observed and applied these to the ‘Strange Situation Test’ (Ainsworth et al. 1978). In this test a baby (between 12-18 months old) is left alone for up to 3 minutes with an unfamiliar person and then re-united with their mother. Close observation is made of what happens when the mother leaves, but more importantly what happens on reunion? It is this behaviour that gives an indication of the child’s attachment status. A child could be classified with either a Secure or Insecure Attachment.
A securely attached child’s response to his mother leaving would be to show some distress but to be able to respond tentatively to the stranger. On being reunited with mother however, the child would greet her positively, and accept comfort and reassurance and then return to play.
Anxiously attached children can be further divided into:
Anxious Avoidant Attachment, where the child would show little/no distress on parting with mother and who would respond quite positively with the stranger, but on return of mother, would avoid her, not seeking her out for any comfort.
Anxious Ambivalent/Resistant Attachment where the child would show much distress on parting from mother, and be very wary of the stranger, but on return of mother would continue to show distress even anger, and refuse to be comforted easily. Returning to activities/play would be unlikely.
Main (1995), having studied how children responded in the Ainsworth Strange Test, later identified another group of children whom she described as having Disorganised Attachment, where the child would show contradictory behaviour on being reunited with mother. When the attachment figure is frightening to the child, the child has no strategy to cope and is left feeling helpless.
Insecure patterns of attachment have developed as a defensive response to parents who have for whatever reason been unable to provide them with a secure base. Instead of helping the child to manage difficult feelings and acting as an emotional container (Bion) or providing the child with emotional holding (Winnicott), the parent has been unavailable or unresponsive. In continued attempts to elicit care from the parent the child adapts its behaviour according to the parents’ responses.
In an avoidant attachment the child has to think rather than feel as her parent is often physically and emotionally unavailable. To cope the child generally puts away all feelings, behaves well and keeps her distance, and in this way she will not be abandoned as feared.
In an ambivalent attachment, the child has learned that her parent is over emotional and unpredictable and the way to get her needs met is by crying, clinging or having tantrums. A lot of energy is expended in attempting to match her parents’ emotional responses so that play and exploration are neglected and feelings rather than thinking are activated
The child with the disorganised attachment has had to adapt her attachment behaviour in response to severe neglect or abuse. Neither thinking nor feeling will help the child in this case. ‘This group is perhaps to be equated with Winnicott’s ‘unintegrated’ child’ (McMahon: 2001:53). Any bad feelings cause these children to emotionally fall apart.
Crittenden (1995), a student of Ainsworth in the early 80’s, added further sub-classifications of children’s responses to attachment experiences as they became older. Her model is represented by a pie chart as shown in appendix 1
Securely attached children are categorised as B3 children (secure and integrated). To either side of B3, is B1-2 to the left which represents a secure but reserved category, and to the right B4 which represents a secure but reactive group.
C children which are a continuum of the B4 group and again further to the right are the children classed as ambivalent who are distrustful of cognitive information and rely on affect. These have been further classified into C1-2 children who may be threatening or disarming, and C3-4 aggressive or helpless. In school age children, a further category of C5-6 represents children who are punitive or seductive.
To the left of the B1-2 children are those represented by A, these are the avoidant group, further classified into A1-2 an inhibited group, A3, compulsive caregiving children and A4, compulsive compliant children. These children will rely on cognition alone suppressing their own feelings.
The group of children previously classified as having a disorganised attachment belong in the AC group, which are to the left of the A group and to the right of the C group, inevitably meeting together at the lower half of the pie chart. They are children who have no organised defence strategy and alternate between the two patterns of behaviour, either being aggressive with adults or other children or using exaggerated helplessness to ‘maximise caregivers attention’ (Crittenden 1995 cited in McMahon and Ward; 2002:6)
‘The importance of assessment to those providing services is reflected …in the extent to which professionals have devised their own assessment procedures… tailor-made methods of meeting local needs.’ (Hogg and Raynes 1987:10)
The Chambers Twentieth Century Dictionary defines ‘assess’ as ‘to fix the amount of’ or ‘value of’ and ‘assessment’ as ‘the act of assessing’. It is a way of measuring, and in the context of this work, assessment is a tool to ‘measure progress’ towards ‘recovery’.
When I searched the internet using the Google search engine for ‘Assessment’ I was directed to the Directory of over 1000 Assessments but was unable to find an assessment that related to child care other than in the field of Education. A more extensive search using the words ‘child’ and ‘treatment’ in addition, found sites for assessment in specific disorders such as such as ADHD, Autism, Bipolar Disorder, Dyslexia, Speech and Language and Reactive Attachment Disorders.
Adding ‘Psychodynamic’ to the mix, I found several sites that looked at Projective Techniques of assessment for children such as the Rorschach Inkblot Test based in the Freudian and Neo-Freudian School of psychology. Freud believed that there were only two distinct drives that motivated people: - aggression and sex, but that they were buried so deep in their unconscious by defence mechanisms, that they remained hidden even from the individual. One of these defence mechanisms is projection, where for instance a person’s unconscious need for aggression may be projected onto another. The aggression can then be disowned by them and criticised in the other. Projective techniques in assessment use this theory, so that the child can project their own hidden feelings into a character in a story, a puppet, a drawing or other symbolic form without provoking the anxiety that would be present if they were to own their feelings. ‘These projective techniques are gaining more and more research support as they become more standardised and researched, but they are still open to a lot of different interpretations.’(Heffner Media Group Inc.2004)
The Framework for the Assessment of Children in Need and their Families jointly issued by the Department of Health, Department of Education and Employment and the Home Office in 2000, is an obvious starting point for those involved in the work of caring for children. The framework has been developed to provide a systematic way of ‘understanding, analysing and recording what is happening to young people within their families and the wider context of the community in which they live’. (Gray cited in Howath 2006: 9) We are reminded of Winnicott’s book entitled ‘The Child, The Family and The Outside World’ (1964).
The Framework is designed to assess whether a child is in need and if so what actions and which services would best meet that need. It builds on and supersedes the earlier Department of Health guidance on assessing children, ‘Protecting Children: A Guide for Social Workers Undertaking a Comprehensive Assessment’ (1988). It is more time bound allowing only 7 days from the Initial Assessment for an outcome, and enabling a more speedy response within that time for the Core Assessment to be initiated should the child be in immediate danger. In criticism of the assessment the Joseph Rowntree Foundation (1999) complains that there is no opportunity for the child to have their views taken into account ‘as stated in the United Nation’s Convention on the Rights of the Child.’(op cit)
It is designed to help professionals adopt a common approach to deciding whether a child is in need and how best to respond to the identified need. Seven interlocking dimensions are identified as necessary to progress for children to achieve long term well being into adulthood. These dimensions are as follows -
Education
Health
Identity
Family and Social Relationships
Social Presentation
Emotional and Behavioural Development
Self-Care Skills
‘Progress along all of these dimensions is important for all children regardless of their race, culture or ability’ (Ward 2006:172)
The ‘Looking After Children; Good Parenting, Good Outcomes (LAC)’ system which developed in parallel with the Children Act 1989, after a piloting and revision period (1991-95) was implemented between 1995-1999. It was until recently the main planning system for looked after children in most local authorities across England. The Action and Assessment Records were used to measure the achievements in children’s progress, along with the standard of care and led to a plan for improvements.
Integrated Children’s System (Jan 06) has merged LAC with the Framework, to provide a seamless information gathering and planning system from the first referral of a child through to rehabilitation or permanent care. Where a child’s care plan requires that they are ‘Looked After’ then an Assessment and Progress Record should now be used to assess and monitor developmental progress.
ICS is in transitional stages at present and as yet, I am not aware of any local authorities with which SACCS are currently working where we have been asked to help complete this new form of paperwork.
With over ten years of experience of completing LAC Action and Assessment Records, I feel in quite a strong position to make comment on their various strengths and weaknesses.
The responsibility for the full completion of each dimension of the Action & Assessment Records lies with the Local Authority Social Worker. Social Workers usually distribute documentation at a child’s LAC Review and the expectation is that over the next reviewing period the staff in the home will help the child to complete it. However, by the following review if the document is not complete it is carried over to the next review. The booklet is quite a daunting document and requires additional assistance from schools and health workers. Finding the opportunity to do this is difficult. There is rarely any urgency on the part of the Social Worker and staff take their lead from this and often fail to complete it. If completed, Social Workers usually take it away to conclude with the plan. This rarely, if ever, makes its way back to the child, rendering it useless.
The most useful aspect is talking to and thinking with the child, ascertaining their ideas and understanding of how they perceive their situation. This can help greatly in planning for their care. It also acts as an aide memoire for aspects of care that may not get paid enough attention such as visits to the library.
The question is whether this assessment provides enough information to plan for the care of traumatised children? In my opinion, it gives an overview and offers some broad guidelines in all seven dimensions, but it doesn’t pay enough attention to the detail to provide a comprehensive treatment plan. ‘When you look to the literature on assessment, what you tend to find is that it encourages you to think broadly rather than deeply’ (Ward 2004: 4)
Barbara Dockar-Drysdale was the founder and director of the Mulberry Bush School, (1948-63) a school for what were described then as ‘severely disturbed and deprived children.’ She later became Consultant Psychotherapist to the Cotswold Community a therapeutic community which had evolved from an approved school. Her work was greatly influenced by Dr. D. W. Winnicott who was her mentor. Winnicott’s contributions to the development of child psychotherapy and psychiatry stemmed from theories of Anna Freud and Melanie Klein. Like Winnicott, Barbara Dockar-Drysdale attached more importance to the earliest period of infancy than did Anna Freud.
During her time at the Mulberry Bush, Dockar-Drysdale devised a Needs Assessment (1970). She was clear that there is a considerable difference between a referral needs assessment and an ongoing needs assessment, and clear that in both cases ‘all needs assessments, must in my view be made by a group, never by an individual collecting information or depending upon interview procedure.’ (1970: 94)
It came into being in order to classify children on arrival at the communities as either ‘integrated’ or ‘unintegrated’. Categorising children in this way and considering their stage of integration would lead to formulating a picture of their needs and a plan to meet them.
Dockar-Drysdale believed that questions designed to determine classification could only be answered by a group of residential workers who had lived with the child for at least three to four weeks. The discussion would be led by a senior worker who could lead the group in the discussion by asking and explaining the questions and by recording the answers.
To determine whether a child belonged in the ‘Integrated’ or ‘Unintegrated’ category, only two questions were pertinent, that is: -
1) Does the child panic? (Unthinkable anxiety - almost a physical condition.)
2) Does the child disrupt?
If the answer to these questions were yes, then the child was considered to be ‘Unintegrated’ and further questions would be applicable to determine into which further category the child fitted. The four categories were:
Frozen
Archipelago
False-self
Caretaker-self
Four more main questions remained:
1) What is the ‘syndrome of deprivation’? (the state of feelings in the child in regard to :- personal guilt, dependence on others, merger, empathy, stress, communication, identification, depression, aggression.)
2) Capacity for play?
3) Capacity for learning?
4) Capacity for self-preservation?
From the answers to these questions which are not ‘yes’ or ‘no’ answers but answers which have come from the real experience of living with and being close to the child, it would then be ‘usually quite possible to make a good guess at the stage of integration reached’. Each classification would have a general list of needs for which a treatment programme could then be put together to treat the child. For example, for any child who was classified, as ‘Frozen’ there would be a list of needs to be met such as ‘containment’. The treatment programme would then detail how the need of containment could be met.
An ‘Integrated’ child’s needs were also detailed but were considered to be far more individual in nature.
The strength of this assessment lies in the fact that the people who know how it feels to live with the child are the ‘experts’ in determining into which category a child fits. A senior person is available to help as a guide through the assessment but ultimately it is the workers who own the classification and can begin to own the treatment. There are clear guidelines for how to meet the needs of a child once classified and the treatment plan appears to be very straightforward.
Conversely, the fact that classification leads to a prescribed treatment plan which has been designed by an expert (Dockar-Drysdale), may leave some workers feeling quite constricted and unable to use any of their own creativity. Also, the needs of the children who are classified as ‘unintegrated’ appear to be clearer than those classified as ‘integrated’.
I am aware that while the Cotswold Community continue to use the Needs Assessment, the Mulberry Bush School no longer does. In its place is the Boxhall Profile (1998), an assessment which originally provided a framework for ‘the structured observation of children in the classroom…. to enable teachers to plan focussed intervention.’ (Bennathan: 1998:3)
In London in the 1970’s Nurture Groups were being set up in areas of severe social deprivation. Educational Psychologist, Marjorie Boxall created nurture groups in some schools for children who were showing early signs of emotional and behavioural difficulties. These were small special classes with specially trained staff to provide a structured and predictable environment in which the children could begin to trust adults and learn. The Profile was developed because ‘teachers wanted a more precise way of assessing need, planning intervention and measuring progress.’(op cit: 4) Its effectiveness was not confined to children within the nurture groups but soon spread to the whole school.
The DfEE‘s paper ‘Excellence for all Children: Meeting Special Educational Needs’ (1997) claimed that experience of using the Profile assisted in the policy of inclusiveness, enhanced teacher’s skills in managing children with emotional and behavioural difficulties, and developed strategies that lead to effective early intervention. The paper promoted the use of the Profile for all teachers.
The structure of the Profile is divided into three sections: -
Developmental Strands
Diagnostic Profile.
Factors Likely to Affect the Scores
The first two sections consist of 34 descriptions of behaviour that are scored and entered onto the corresponding histogram. The first section consists of items that describe aspects of the developmental process of the early years. The second describes behaviours that inhibit or interfere with the child’s satisfactory involvement in school. Each question is scored between 0 and 4 with a key for scoring each section.
Two clusters are identified in this section with five sub-clusters relating to each.
Organisation of Experience
Internalisation of Control
Each of the 34 descriptions is scored to a particular group (sub-cluster) and each group to a cluster. For example, questions 14, 21, and 26 are in the sub cluster Participates Constructively. That in turn belongs to the cluster Organisation of Experience. The histogram is a visual representation of the child’s level of functioning and each sub-cluster is represented in a column, there is a shaded area that shows a comparative average score for competently functioning children.
Three clusters are identified in this strand
Self-limiting Features
Underdeveloped Behaviour
Unsupported Development
They have two, three and five sub-clusters respectively. The two latter clusters have sub-clusters that relate to ‘Attachment’.
The third section scores factors such as visual impairment, limited understanding of language, medical conditions or other factors that may affect the scores obtained from the first tow sections.
For each of the sub-clusters there is in the Profile an interpretation of what the score in that particular sub-cluster shows. In the example given above, a high score indicates an interested and purposeful involvement with people and events, and some autonomy of functioning and learning.
The descriptions are very straightforward and specific making them easy to score. Grouping the answers into sub-clusters and clusters that are then interpreted appears to take care of the ‘thinking’, but planning an intervention consists only of samples. The visual representation in the histograms of the progress made by the case studies was impressive and the comparison to ‘normal functioning’ allows perspective. I suspect that this profile is generally completed solely by a teacher, making it a very subjective view. However, for its purpose in school I think that it would be very useful. ‘The Profile is extremely popular and regarded by many users as unique in the insights it generates in the development of children across a wide age range.’(Boxall:45) I understand that when used by the Mulberry Bush School it is done as a collective in much the same way as in the Needs Assessment. In the ‘coming together’ would lay its strength.
This Assessment Programme claims to start where the ‘Looking After Children’ assessment finishes and focuses on the ‘emotional world, that part of the personality which, through chronic suffering, triggers anti-social behaviour and problems of care and management.’ (Bradley and Hardwick 1999: 114) It aims to provide practitioners with diagnosis and practical signposts for placement and suitable treatment including education.
Twenty dimensions of a child’s personality are identified in the assessment as needing to be addressed to successfully intervene and bring about change for a child. It is suggested that about 8 dimensions are selected to work with initially and following the assessment that a 24 hour management programme is drawn up to ensure team consistency and reliable parenting.
The Assessment is divided into three sections; the first section identifies 10 dimensions that lie at the heart of a healthy personality.
Boundaries
Capacity for concern, empathy, remorse etc.
Containing emotion, anxiety, anger, stress
Delinquent excitement
Communication
Dissociation
Self-destruction
Separation / loss
Violence /aggression
Play
Each dimension is divided into 5 ‘types’ and labelled A-E. Against each letter the ‘type’ is described. The child is then matched to their nearest type, and an action is outlined to ‘manage’ the child. Signs of progress are suggested and a further action suggested.
If a child were to have a low score in this section (mainly A’s or B’s) it would strongly suggest that he was not suitable for adoption or fostering. He would be considered to be very ill and require primary provision in a residential setting to make good the deficit from his earliest relationship.
The second section provides further help in diagnosing further problems and suggesting solutions by looking at 5 more dimensions.
Defence mechanisms
Depression
Meeting primary needs
Potential psychotic areas
Self-preservation
The third section has 5 more dimensions which are ‘very much part of the way forward’ (op cit: 116)
Creativity
Ego function
Environment: making use of and contributing to one’s own
Identification
Learning from experience
The assessment is a team exercise, ‘No one person can assess a young person’ (op cit: 118) and it is suggested that other significant colleagues such as teachers also participate.
The theoretical underpinning for this programme stemmed from 25 years of research spearheaded by Dartington’s Social Research Unit. Clinical studies of Winnicott, Dockar-Drysdale and the Tavistock Clinic have also had a strong influence with some Kleinian aspects.
The obvious strength is the theory that underpins the whole assessment. It is a very thorough document and very helpful in not only pinpointing behaviours but also suggesting ways of helping the practitioner to manage the behaviour. Yet it is not done in such a prescriptive way as to ‘take away’ the thinking from the practitioner. It reminds and suggests ways forward. It also describes what progress might look like. Sometimes progress is not recognisable, such as in the dimension of ‘Depression’ progress is described as ‘can be depressed for significant periods of time’ (op cit 154).
The biggest difficulty I can see with the assessment is the sheer volume of it. The twenty dimensions are spread over roughly 80 pages. Whilst it is advised for staff only to work with about 8 dimensions at once, there must be a significant amount of time needed to wade through the weighty tome identifying the dimensions to use.
Assessing attachment in children is commonly assumed to be dependent on their age. Farnfield’s Table as shown in appendix 2 provides a useful guide. Common to all age-groups is the importance of the history and observation. Play is an indicator up until adolescence while specific tests such as story stems and interviews are not useful until a child is 4 to 6 yrs. To measure adult attachment there is a specific test designed by George, Kaplan and Main (1985) called the Adult Attachment Interview which relies on close attention to how a person tells their story interpreting whether they are able to view their experience from an adult perspective or continue to think as they did as a child. .
In assessing a child for treatment within the care setting the history and observation continue to play a big part. Attachment difficulties that have originated within the birth family will mostly be identified by the child’s behaviour in substitute relationships. Fahlberg (1979: 40) sets out an observational checklist, to be found in appendix 3, of the long-range effects of the lack of normal attachment development Howe and Fearnley (1999: 22-23) table the symptoms of an attachment disorder shown in appendix 4. Howe (1995) states that in making an assessment we need to consider, present relationships, relationship history and the context in which this is set. He believes that we need to take time to study these so as not to ‘jump straight from problem to solution’.
In my literature search I have only found one assessment format that is specific only to attachment. Zeigler (2001) has produced an Attachment Disorder Scale that is in three parts.
Development History
Quality of Relationships
Personality Traits
Certain factors need to be ruled out before the assessment such as medical problems, active child abuse, environmental pathology, and other childhood diagnosis.
At the end of the assessment the scores from each section which range from 0 to 2 are added together to give a total which indicates the severity of the attachment disorder.
The assessment is straightforward to use with questions that are easily understood and easy to score. It can be done as group or by an individual. The indications at the end however, which would then inform treatment only indicate the severity of the attachment and not the pattern. In the most severe category the recommendation to refer to a specific residential treatment centre could be confusing. It appears to be designed only for an initial assessment rather than as an ongoing process. Subsequent assessment may only show improvement in the second two sections, the static score in the first section reminding us that we cannot alter history. It is helpful in identifying behaviours of children with distorted patterns of attachment and more so in describing how it might feel to care for such children .This part of the assessment is shown in appendix 5.
In order to obtain a balanced view of SACCS Assessment Process and hopefully a more authentic picture, I take a qualitative approach and use four methods of collecting data: a small-scale survey, a literature review, my participant-observation and a review of company data already collated. This should give what is described in Fuller and Petch’s glossary (1995) as ‘triangulation’ that is using more than one method of collecting data about the same thing. Smith (1975) said that ‘Each method, tool or technique has its unique strengths and weaknesses’ (cited in Saunders et al. 2000) By using several methods there can be a more rounded view formed that is less affected by any one method used, and less likely to be biased.
Fuller and Petch (1995:201) define qualitative research as ‘data or analysis which is rich in the detail or particularity of individuals’ experiences, perceptions or definitions of their situation, often with a small sample.’ Whilst Best (2002) describes this approach as a means of understanding ‘the richness and subtlety of human experience … in its unconstrained complexity.’ In the work that we do this type of enquiry is how we begin to make sense of what is going on around us. If we use ourselves as the tool by which children are helped towards recovery, we inevitably will need to ‘immerse ourselves in the lived experience of others.’(op cit) In order to understand whether the Assessment Process is helping children make better relationships with adults and other children I am very much involved in the process itself. I am participant-explorer and as such pay as much attention to my own part in the whole process as I do to that of others.
My original plan for a small-scale survey had to be altered. I will first outline that plan and then explain how I had to adapt it. What I learnt from reflecting on this process will follow later as a chapter entitled ‘Personal Reflection’.
I intended to work with just one team to find out how effective they find the SACCS assessment process in helping them to produce plans which encourage the attachment process for the three children in their care. I wanted to find out whether they understood what they were being asked in the paperwork, whether the scoring system was helpful and whether ‘attachment’ was covered well enough in the discussions that followed. Ultimately, I wanted to know whether a low score in this area led to productive discussion, which in turn led to a good plan. If a good plan was achieved, did this then lead to recovery (a higher score next time) in the area of attachment? I would investigate this by producing a questionnaire.
I realised that in my position of Deputy Director, it could appear that I was using my power to secure an agreement to participate from staff, so as a safeguard I intended to ask a third party to stay with the staff whilst they completed the questionnaire. In this way I would overcome what Bell described as ‘Non-response’ (Bell 2005: 149) but without the pressure my presence might exert on staff. I intended to make it clear that anyone not wishing to participate would be free to make that choice. The answers would be neither ‘offensive nor pleasing’ to me as I had no personal nor professional investment in the nature of the responses. I intended to assure them of anonymity when I reported my findings, which would be more general than specific. Staff are already used to reviewing the assessment process through questionnaires, and are aware that their views are important in helping to shape the future of the process. Participating in this survey would not be outside of their normal parameters.
At the planning stage of this survey I had overall responsibility for four of the nine Homes within the SACCS portfolio within the Shropshire Region. However, earlier this year another Deputy Director of Practice was appointed to the Directorate in our Region. My responsibility for one of the Homes has now passed to my colleague. It is the Home that I had planned to use both for my small-scale survey and for participant – observation.
In addition to this, my Dissertation Proposal took until June 2006 to be completed and approved. This meant that I was unable to proceed with this part of the study until I was sure the proposal was ethically sound. The dates of the assessments for the three children who were looked after by that Home had come and gone.
The SACCS Assessment Process comes to a halt for the children’s school summer holidays. This meant that not only had I missed the dates for those three children but that I had missed nearly all the dates available until the next round of assessments which wouldn’t begin until September 2006.
My own holidays prevented me from attending some of the remaining assessments, until eventually the choice was really narrowed down for me. I was only able to attend the assessment of one child for whom I currently hold any responsibility. The other two I had to ‘borrow’ from my two colleagues.
As I now needed to work with three different teams as participant-observer, I felt it appropriate to canvass the views of all three teams. Upon further consideration I felt that it would be very little extra work for me to ask all nine teams to participate. It would also give greater depth to my study. ‘The size of your sample …will have implications for the confidence you can have in your data’. (Saunders et al 1997: 281)
I prepared the teams for the questionnaire by writing a letter (as shown in appendix 6) to the Manager of each team explaining its purpose and assuring them of their freedom of choice in completing it as well as of confidentiality and anonymity. I made my Dissertation Proposal available to them should they have wished for any more information. In addition I spoke directly to individual manages prior to handing them the letter and their questionnaires.
Although it was my intention to meet with the Therapy Manager and the Life Story Manager I ran out of time to arrange meetings prior to the first Assessment. I therefore left the letters and questionnaires on their desks. I felt uncomfortable at not being able to prepare them and pave the way with a verbal explanation but had left myself little choice at this stage.
I was satisfied with the response received from the Therapeutic Parenting Teams. I felt that I had prepared them well. For six of the nine teams, I chose their team meeting day to brief the Manager and to distribute the paperwork, gathering the returns straight afterwards. The three remaining teams had their meetings on my ‘study’ day so I distributed the paperwork to the Manager but had less control over its return. If staff were absent from the team meetings, they did not have the opportunity to participate. Due to the timing, there were fewer members at the meetings as they were needed in the homes to look after the children.
With the Therapy and Life Story Teams, whom I had not prepared so well, relying only on the letter of explanation, I had less success, I received only a few replies that were placed on my desk in a mirroring of the way I had given them out.
I have used my reflective journal to reflect on my thoughts feelings and reactions during assessment meetings about the child, the group and the process as a whole. ‘One of the chief tools for understanding the child’s emotional world is counter-transference, the worker’s feelings in response to the child’s projection of feelings into the worker.’ (McMahon et al 1996) Remaining attuned to my own feelings, I can think about what resonates with my own history, making me sensitive to the child through what is being felt by the workers.
In my usual role, it is customary for me to make notes and to meet up with the facilitator and observer in the 10-minute break to pool thoughts, ideas and observations. In my dual role of participant -observer, I have ensured clarity by providing the team with an explanation and ascertaining consent.
As a company we are currently on the 5th round of assessments and the paperwork for all previous assessments has been made available for me to study. I have restricted myself only to the data available on the children currently being cared for. I have made a comparison of the attachment scores with the scores in the other developmental areas and have considered the progression of the scores for a child during placement
Members of the Practice Research and Development Department have devised the assessment format under research, so I have sought permission to use it as part of this study as shown by the letter in appendix 7. I have been quite clear about expectations for both parties. My organisation paid for my TCC course and will be very interested in the outcome of this study. In time it is hoped that the SACCS Recovery Assessment will be published and the company are keen to keep it under review. I have made every effort to report impartially and expect my findings to be respected. I am aware that my own attachment history pre-disposes me towards wanting to please, and to presume the Company to have a preferred outcome. Equally I have considered the possibility of subconsciously using the study as a cover to allow me safely to project a darker side. I have worked hard to avoid this and report only as I find.
In order to provide confidentiality to the children whose assessments or plans I have used in this study, I have protected their identity by using pseudonyms and I anonymised them by changing details of their age, sex, appearance or history. I carefully weighed the potential benefits of this study against any possible harmful effects to the children, and given the protection of anonymity I believe that the risk of children being harmed is minimal. Also, I have used only vignettes and not a full case study. The enquiry has been based on work that is carried out within the normal bounds of my professional role and complies with the University Ethics and Research Committee’s Guidance to Departments.
The teams I worked with were given assurances of confidentiality and the questionnaires were filled in anonymously. My records of the observations did not identify any individual in any way by name or position. I was careful not to use my position as Deputy Director to ensure compliance but liased with the teams through their Managers. I gave a full explanation of the purpose of my enquiry to the Managers and made it clear that staff could opt out of filling in the questionnaire. The choice whether to participate remained with the individual.
As part of the Assessment Process, I was not an impartial observer as I had a role to play both as Deputy Director and as Researcher. I needed to pay particular attention to my dual role, and keep records of anything that I felt, said or did, as any part that I played would have an effect, even if it was to remain silent. As Mason (1996) suggests I needed to ‘constantly take stock’ of my actions and ‘subject these to the same scrutiny as the rest of the research data.’ (cited in Best 2002) Abbott and Sapsford (1992) refer to ‘Reflexivity’ as the ‘sharpest tool’ for constantly reflecting on the ‘content and process of the research and trying to be one’s own critic.’ (cited in Best 2005)
As I worked my way through each stage of the methods I selected to use, I looked closely at my findings and whatever I learnt changed how I analysed the subsequent methods. I did not rigidly stick to the plan if I didn’t think it was going to flow from one set of findings to another, I sometimes found myself taken in another direction. I remained open minded to any opportunity that presented itself and followed my interest and curiosity.
SACCS is an independent childcare company offering an integrated service to severely traumatised children who are aged between 4 and12 on admission. It has been established since 1987 and currently has the capacity to look after 60 children in the Shropshire and Midlands area.
Children who are admitted to SACCS have usually suffered from early childhood trauma in the form of profound neglect and/or abuse, physical, emotional, psychological or sexual. This early abuse and deprivation has led to severe emotional and behavioural difficulties. These have further been compounded by placements in substitute families, who do not have the skills to deal with such difficulties, causing the placement to break down. It is not unusual for a child to have had between 10 and 20 prior placements and often more.
The company offers an integrated approach to childcare. The children receive Therapeutic Parenting in residential homes, Individual Therapy and Life Story Work. The departments providing these therapeutic services work together as the ‘Recovery Team’, are all employed by the company and trained together in the SACCS approach to recovery.
The residential homes are large family sized houses based within the local community, which are indistinguishable from other family homes. Between 3 and 5 children are cared for in each home by a Manager, Deputy Manager, 2 Seniors Care Practitioners and a care team of 6 or 7 Residential Care Workers dependent on need. They provide a child-centred, safe and nurturing environment which aims to allow the child to begin to trust others to meet their needs and to provide individual experiences to fill the gaps in their formative experiences.
In order that a child might form a healthy attachment, he is matched with a Key Carer. Through this relationship it is intended that the child will enjoy the experience of ‘a level of preoccupation akin to maternal preoccupation normally associated with infancy’. (Rymaszewska and Philpot 2006:23) The Key Carer assisted by a Supporting Carer will ensure that the child’s physical and emotional needs are met.
The child is supported to access a mainstream school and to take part in community based activities in order that she does not become isolated. In this way it is hoped that she will begin to form friendships when ready, with children from the local area.
As play is the medium in which a child naturally communicates, play therapy is the therapy of choice, but therapists also use art, dance and music. Older children sometimes prefer the option of a talking therapy. Therapy helps a child to ‘explore her inner world, and slowly examine some of the harmful experiences in the past….. and to externalise them so they no longer have power over her.’ (Walsh 2006 cited in Rymaszeska and Philpot 2006;10)
Each child is allocated a Life Story Worker who through examining case files, and interviewing significant people in the child’s life, such as birth parents, extended family, foster or adoptive parents or any ex-carers, builds up a picture of the child’s past. This is shared at the child’s pace, with the child who is supported by their key carer. The child is then encouraged to add his own memories and feelings and a Life Story Book is created. In this way the child’s past is ‘faced, analysed, understood and, finally, accepted.’( Rymaszewska and Philpot 2006:23 )
SACCS also has a family placement agency where children can continue their recovery within a family setting once they have been assessed as ready for this next step. The families work closely with the recovery teams to move a child on smoothly and have access to the same training as rest of the Recovery Team.
I have worked for SACCS for almost ten years: - starting as a Deputy Manager of a 3- bedded home, I soon progressed to being Manager of a 5 -bedded home where I remained for eight years. I was promoted to the position of Deputy Director of Practice two years ago which, is where I currently remain. An organisational map is included in appendix 8.
An organisation’s primary task is defined by Menzies- Lyth as ‘the task which the enterprise must perform in order to survive’ (1979:22) and by Ward as ‘that which it must be seen to be achieving if it is not to lose its supply of referrals or even be closed down.’ (2001:40). SACCS ‘primary task’ is the ‘Recovery of Traumatised Children’.
A Recovery Assessment Process was introduced into practice by the Practice Research Development Department (PRD) approximately 2 ½ years ago, a tool to aid in the ‘Recovery’ of children. Recovery is defined against 24 outcomes as outlined in appendix9.
The process involves each service delivery area (Therapeutic Parenting, Therapy and Life Story) completing a Recovery Assessment form for each child every six months. The form is divided into 6 areas of Child Development. These are
Learning
Physical Development
Emotional Development
Attachment
Identity
Social & Communicative Development
In each section there are between 3 and 6 questions asking the assessors to score the child between 1 and 4 and to give underpinning evidence.
The ratings are as follows:
4 = No real concerns; satisfactory functioning in this area
3 = Minor concerns; one or two aspects to address
2 = Moderate concerns; some signs of progress but a range of aspects to address
1 = Substantial Concerns; poor functioning in this area
The results of the scores are then plotted onto an Assessment Score Summary Graph which gives a representation of the child, this is shown in appendix 10. This concludes with a summary of the assessment that asks for an estimation of the child’s overall development and also an understanding of the child’s internal working model. (Bowlby 1969)
When the paperwork is completed and collated, it is distributed with a summary of the Child’s History to: PRD, Therapeutic Parenting, Therapy, Life Story and the Deputy Directors of Practice. In this way, everyone who has a part to play in the child’s recovery has had the opportunity to view the child from another’s perspective. The child chooses a photograph that they like for use in the assessment discussion. This is put onto acetate so that it can be projected onto the wall for all to see during the discussion.
On the day of the assessment the whole recovery team is expected to attend with the responsible Deputy Director of Practice. A member of the PRD facilitates and leads the meeting that lasts for 1½ hours. Occasionally there is also an observer from the PRD who does not join in the discussion but observes the facilitator in role and the recovery team. For the first 50-minutes, the child’s photograph is projected whilst he is discussed: the assessments are examined and compared both to each other and to previous assessments. ‘This method of plotting a child’s progress avoids drift and helps staff to focus more clearly if they need to come up with new strategies to help the child move forward.’ (Tomlinson 2004)
Participants are then encouraged to discuss how they feel about the child and how the child impacts on them. This is a ‘reflection process’ (Mattinson 1975), the unconscious process whereby the worker, in supervision may project into the supervisor feelings transferred from the client. Strong feelings within the group can reflect strong feelings within the child. A staff team who feel unable to help a child are often mirroring the child’s own feelings of helplessness. ‘The concepts of transference, counter transference and projection are necessary and useful tools for the worker. They can help in understanding how the child is feeling and experiencing the situation and what he might have experienced in the past.’ (Tomlinson 2004:133) It is by paying close attention to the process of ‘reflection’ that ‘we can often use what we discover to help us to decide how to respond to what is happening’ (McMahon and Dacre 2001: 85) The skill of the PDR is to help the team make the connections.
Following the discussions, there is a ten-minute break whist the facilitator, observer and the DD retire to think about the assessment discussion and return with some ideas of what areas need further development to enable the child to continue towards recovery. In the final 30 minutes the group reconvenes to discuss these thoughts and ideas and discuss how they are going to be put into practice. The recovery team then amends the child’s Individual Recovery Plan. Once amended, the plan will be shared with the child and the child’s social worker. It will be monitored in weekly team meetings, and at the 3-month stage, and altered accordingly.
On average it is expected that a child will take approximately three and a half years to complete their recovery. ‘Through internalising their attachments and the experiences that they undergo in an accepting environment and with therapeutic parenting, the children are able to reach a level of recovery which enables them to move successfully on to family placement and achieve their potential.’ (Rymaszewska and Philpot 2006: 24) Indications of timescales for a child to reach recovery are predicted by the PRD in consultation with the Regional Directorate. This is an important aspect to purchasers of our service who are keen to know how long our service will be necessary. Miller (1993) and Menzies-Lyth (1988) would describe SACCS as having an ‘open systems’ approach in that traumatised children are admitted, (‘imported material’) worked with, (‘processed or transformed’) and then discharged to a family (‘exported’). The length of time for the transformation to take place will determine the cost of the whole process. In these times of apparent short resources, an approximate answer to this question is very important to purchasers of the service. The assessment process is the tool used to assist in this measurement.
This chapter will be sub-divided into three sections relating to the methods used to examine the SACCS assessment
In this section I examine the results of questionnaires distributed to staff. I look first at the answers to questions requiring only a ‘tick box’ type answer before inspecting the comments made on questions requiring a comment. After each group of questions I summarise what the findings show.
In the participant-observation I begin by examining the assessment paperwork produced for each assessment, analyse the scores and look closely at the underpinning evidence. I then move onto my observations during the assessments and finally inspect the Individual Recovery Plans produced as a result of the assessment.
In the review of data I comment on my findings when studying the assessment scores in the area of attachment in comparison to the other developmental areas.
Out of 110 questionnaires given out, 56 were returned complete. This equates to 51% of the total. The results of the questionnaire and a corresponding dialogue relating to the questionnaire can be found in appendix 11.
What I can deduce from these statistics is that the majority of people questioned had received training in ‘Attachment’ and felt strongly that a child’s early experiences were important to the Recovery Assessment. Most also felt that they understood the concept of the ‘internal working model’, and that they understood how to work with a child in order to improve her level of attachment.
In terms of the assessment questions, and the scoring system, most people felt that they either understood or mildly understood them and that if scoring was low in the area of attachment that the assessment discussion that followed would pick this up and it would be discussed. The statistics also show that most of the staff agree or mildly agree that the Recovery Assessment helps them to understand how to make positive changes to attachment and that when the IRP is discussed, attachment figures highly in these discussions.
It would appear that staff are almost evenly split about whether three assessment questions are enough to determine attachment. However, those that disagree, do so more strongly than those that agree.
Whether the scoring system was thought to be helpful did rate more positively but there is much less certainty about this, with a lot of people not feeling very sure.
The majority of staff agree that it is more significant if a child has a low attachment score, and not less significant. However, again there was a high number of people who were unsure.
From these statistics, I would suggest that in general staff find the Recovery Assessment mostly helpful in the area of attachment. Only two areas are called into question, one is the number of questions in this section and the other how useful the scoring system is. There are also some critical comments within the statistics but they do not outweigh the overall presentation. This does not mean that they should be dismissed but that attention and respect should be paid and thought given to them. I will address this further in my summary and final conclusion.
For the purpose of this study, I took part as a participant -observer in Recovery Assessments for three children whom I will call Bill, Lee and June.
I begin by examining the assessment paperwork on ‘attachment’ that has been scored by each of the integrated services, (Therapeutic Parenting, Therapy and Life Story) for all three children. I will also explore the underpinning evidence and analyse the scores.
The assessment questions that relate to attachment are to be found in appendix 12
Lee, June and Bill are aged between 10 and 12 years and are at different stages in their care careers within SACCS, Lee and June have lived within our homes for over 3 years and Bill has been with us for just a year. Despite this, all scores indicated that the children are all relatively at the same stage in terms of attachment.
The average score for all three children was between 2 and 2.2 across the three service areas. This indicates that there are ‘moderate concerns with some signs of progress but a range of aspects to address.’ The lowest score was a 1, in relation to question 3. This was accompanied by the comment that Lee had a very low self-esteem and a punishing ego ideal.
The highest score was a 3, in relation to question 2 and underpinned by a comment also about Lee that he showed some signs of improvement, friends now visit, but other areas remain problematic. All other scores were in the range of 1.5 to 2.75 with the majority being at 2 and an overall average of 2.2
An analysis of the scores is to be found in appendix 13
Seven of the nine papers indicate that ‘attachment’ has attracted the lowest score of the six reporting areas. In one of the two remaining papers, attachment scores equally with emotional development and identity for lowest score, and in the final paper, attachment comes mid-way in the scoring.
Three of the nine papers give an indication that the child has an insecure attachment pattern, one goes on to further categorise into an ambivalent style, whilst another suggests the child uses the strategy of coercion. This is rather important because the type of insecure attachment should give the carers some indication of how they can parent the child in order to bring about change. It will also give an indication of how the child is likely to affect the carer.
An ambivalent child with a coercive-aggressive pattern will probably be experienced by parents as critical of their caregiving abilities, making them feel ineffective and worthless. This will provoke their own attachment needs and reduce their ability to respond in supportive ways. (Howe et al 1999:101) They may react to this in one of three ways by displays of anger aggression or abuse, by threats of abandonment and emotional withholding or with moods of collapsed despair in which they feel depressed, unloved, helpless and ineffective.
Whereas an ambivalent child with a coercive-helpless pattern may emphasise their helplessness and vulnerability by clinging and whining, even courting victimisation. This behaviour may force parents into further withdrawal and frustration.
A child with an avoidant attachment has not learnt how to elicit warm, accepting caregiving and has learnt how to be emotionally self-sufficient, they trust only themselves. The more extremely avoidant can exhibit hostility and anti-social behaviour serving to keep others at bay (Mayseless 1996: 209 cited in Howe et al 1999 :66) Any emotionally charged situation will not be read well and short bursts of loss of control may erupt. Looking after this child will leave parents feeling kept at a distance and outwitted.
The child with a disorganised attachment who has not been able to rely on any one strategy may make attempts at both, being controlling and caregiving at times. Their core anxiety is annihilation arising from unresolved trauma and loss, any anxiety will cause a major upset for this child. Parenting her is extremely difficult giving rise to feelings of hopelessness and despair.
Care workers will not be immune to these feelings and the need to understand that these feelings are likely to be provoked is vital. It will also provide important baseline information for informing the IRP in how to work with the child.
From studying what is written on the assessment papers, it is clear that all three children appear to be insecurely attached but it is difficult to work out any further categorisation. June is described as not easy to attach to, keeps me at a distance and has stronger relationship with adults who can keep her safe. This is suggestive but not conclusive of an avoidant child. Lee is summarised by keeps people at a distance, tentatively exploring the possibility of being in a relationship and will test boundaries and consistency to enable him to feel safe. This again suggests an avoidant pattern. While Bill is attributed with attachment to previous carers, presents as not wanting to attach and clear evidence of distress in relation to the departure of members of staff. This may be suggestive of an ambivalent pattern and is backed up by one paper suggesting this.
‘Children differ in the way they respond to being separated from their parents. This response varies from severe depression…… to almost no reaction.’ Fahlberg (1985: 30). As a child’s reaction to separation and loss is the major factor in determining an attachment pattern, it is helpful to read that for one of the children an indication of his reaction was given. Another mentions the possibility of a relationship developing which suggests that progress in the attachment process is beginning and two mention the word ‘safety’ which forms the baseline for the trust in a relationship to begin to develop. ‘For both avoidant and ambivalent children, one of the main issues is the child’s lack of trust in others.’ (Howe 1995: 84)
A minority of one out of nine papers describes an ambivalent style relationship with peers. ‘The quality of children’s relationships with their caregivers correlates closely with the type of relationships they have with their peers.’ (Howe 1995: 116)
June’s quality of peer relationships was unanimously described as dismal and probably was more helpful in defining her difficulties in attachment per se than were the answers in response to question 1.
For Lee there was common indication that peer relationships within the home were problematic. Howe (1995)cites Sroufe (1989a) who cites Fury (1984) in suggesting that two children in a peer relationship with histories of avoidant attachments will not experience much give and take and that in the case of boys very unhealthy relationships may develop. Alternatively, in a relationship between an avoidant child and an ambivalent child the latter are likely to be exploited and become locked into the role of victim. However, in Lee’s paperwork there were also indications of relationships developing with children from outside of the home which is more hopeful.
Bill is described differently by each service area, one suggesting he is a closed book another that he has friends within and without the house but with no suggestion of the quality of the relationships and the other suggesting ambivalent peer relationships.
Bowlby linked attachment to self esteem in that an unwanted child would not only feel unwanted, but ‘essentially unwantable’ (1973: 204) thus mapping his relationships out for life. All nine papers are unanimous in suggesting that all three children have low, very low or poor self-esteem, with only two more hopeful comments where improvements were noted.
The assessment papers, completed individually by each of the integrated services, which allocate a score with underpinning evidence, are the start of the assessment process. In all three of the children’s cases, the evidence from the questions gives good indication that there are attachment difficulties but they struggle to define them accurately enough to stand alone in prescribing a treatment plan.
Further evidence is gathered about the child’s internal working model at the end of the assessment in the summary and gives more indication about how the child is likely to relate to others. Eight of the nine papers show that all three children have IWM’s that indicate that they are bad, worthless, unwanted, or even toxic and that carers are perceived as unsafe, unreliable, dangerous, emotionally unavailable and rejecting or weak and ineffectual. The world and life in general is seen as hostile, scary, unsafe, dangerous, and chaotic. The remaining paper describes how the child may feel in the present rather than describing his original blueprint. This suggests a lack of understanding on the part of the service completing the paper. Howe et al (1999) suggest that the increasing stability of a child’s IWM means that their behavioural and relationship style becomes more predictable and harder to shift. However, they continue by saying that change is always possible with new social experiences to alter the representations and expectations of the worthiness of the self and the availability of others.
This further evidence confirms the earlier indications that all three children are attachment disordered and goes further in helping to define what lies at the very core of the children’s difficulties.
The three assessment discussions, despite paperwork indicating very similar scores in the attachment section, were in fact very different. By coincidence, all three were in fact led by the same member of the PRD so had the potential to follow the same pattern. The therapeutic parenting teams came from three different homes, there was an overlap of therapists in that one therapist was common to two assessments, which was also true of the life story workers. The children who shared the same therapist did not share the same life story worker. I also was common to all three assessments as participant-observer.
It was very noticeable that whilst talking quite warmly about Bill, adults’ facial expressions were blank, body posture was closed and there was a quiet stillness in the room. Although people were not looking at each other whilst talking, most eyes were alert and registering what was going on. There were expressions of hope for and obvious enjoyment of the child and staff were pleased with the progress he had made, yet their body language belied what was being said. I could not make out during the assessment what this meant. Bill’s initial response to people was reported to be one of rejection and it seems that adults needed to protect themselves against this. The ‘frozen’ but watchful body language in the assessment seemed to match Bill’s initial response within the home and indeed his experience within his birth family. We were told that secrets within his family were rife, giving nothing away was obviously very important. Someone described him as defensive and I noted with exclamation marks how everyone around the table looked defensive. Apparently both birth parents have very blank and still expressions too.
The team talked about how sparse Bill’s bedroom was despite help and encouragement to personalise it and supposed that this indicated a lack of attachment. It has taken a whole year for him to begin to lay any claim on his bedroom and it is still very tentative, he is still likely to ‘trash’ it when angry. His key carer expressed how difficult the past months had been for her whilst he continued to ‘rubbish’ her and push her away. The harder she tried, the more she did for him, the further he pushed her. She had found it almost unbearable, but with support she had weathered the storm and there was growing evidence that he was allowing her to get a little closer. She warmly described him as my boy. Others expressed little rituals that they had developed together such as double thumbs up gesture on greeting or a special wave. He appears to be finding comfort in the consistent routines of the home finding them safely predictable, this was thought to be a good sign of an attachment beginning to grow. One person related that when the child first arrived, if he won the ‘Pupil of the Week Award’ at school, he would hide it away, not accepting the praise he was given. However he is now enjoying his success asking for it to be displayed prominently, another good sign of a growing self-esteem.
Despite his progress he remains a difficult child to care for and the team reminded themselves that his IWM left him feeling essentially bad, and feeling that carers were not to be trusted. To alter this he would need many more positive interactions with carers who continued to hold him in positive regard. The team came up with several good suggestions for his plan in the area of attachment and other developmental areas.
In Lee’s assessment, the adults were expressing despair, hopelessness and fear. They openly stated how ineffectual they felt. One member broke down in tears and expressed her ‘heartbreak’ at the child’s situation and begged to know what to say to him. She appeared desperately to want to rescue him, yet knowing that she couldn’t. Another member, who was used to dealing with incidents with other children who expressed themselves more aggressively and with violence, stated that he had never been so frightened as when Lee threw himself down the stairs, with no regard for himself, saying that he had been pushed. He was also reported to have begged a past foster carer to punch him and throw him down the stairs. Yet another member strongly expressed that she couldn’t ‘feel’ any attachment. Lee’s key-carer was off sick and although Lee was fantasising about what that meant he didn’t appear to be concerned, upset or sad. He made people feel guilty for the material things that they had and that he hadn’t, he was envious and spiteful. His powers in isolating staff and making them feel pursued was described as ‘targeting’. It was felt that one member of staff had become ill through the stress of being continually on the receiving end of this powerful attention. Another expressed his guilt at not recognising the situation earlier and his own feelings of inadequacy in failing to prevent it. It was suspected that Lee sabotaged relationships so that he would not be rejected first. He was experienced as fragile and angry, members of the group were prepared to go so far as to say, how can you ever recover from a history as damaging as this one? I felt that a disorganised attachment was clearly being described.
Yet there was evidence that this child was making some progress. I heard the depth of emotion expressed from the team, but I couldn’t feel it negatively. It wasn’t until much later when writing my personal journal about the experience that I was able to recognise what I did feel. Strangely I had felt warm and cocooned, a contained and secure feeling. I think I felt what he must feel being looked after by the team. They had such passion and understanding for Lee that I think he must feel that he is in a safe place. He has allowed himself to play with nursery toys again and staff are playing with him. He is starting to talk about his relationship with his mother, something he hasn’t done before. He is asking for care from staff that he may be starting to trust. There is evidence that he is beginning to reflect and wonder. He may also be feeling easier about his appearance as he has allowed himself to be photographed in his glasses. These are very hopeful signs for a child who has suffered from such a profoundly damaging start to life. Attachment was identified as being the major problem for this child and it was suggested that work with him about his earlier losses, not only in Life Story but within the home too would help him. Taking an interest and sharing his Life Story Book with him would be a good way forward.
In June’s assessment the adults were depleted and defeated. They used expressions such as on my knees, too tired to think, can’t go on, it’s an effort to reflect back that you like her. Staff were split into a few who were still willing and on her side to the majority that had apparently given up because it was too painful to keep trying. People talked across one another, fidgeted, and talked to each other outside of the assessment. There was eye rolling and head shaking. The whole team was present (very unusual) and at times the noise in the room was loud and forceful. I reflected in my notes that I did not want to be there. I stepped back from the involvement and listened not to what was being said but how it was being said and could feel the anxiety, anger, fear, and despair. There was also exaggerated laughter from some areas of the room and a real confusion of emotion. The assessment itself ran on and on beyond the tight boundaries that are in place. People were also eating, something that is not allowed in this space, I reflected that people were hungry for a way to meet this child’s needs. One of the team later indicated to me that the overrunning of the session had made her furious with the facilitator. (Not just cross or put out.) She looked sceptical when I pointed out the possible projection. The feeling of an inexhaustible need was palpable.
Reference was made to the fact that June had not only not made progress, but that she had regressed in all reportable areas. She was reported to be scared of herself, and scared of becoming violent like her father, and of despising of her weak and ineffectual mother. The real child was unknown. Her impact on others was described in such terms as huge, frightening, rejecting, bottomless, exhausting, hateful and despairing. She was physically aggressive when anxious and unable to use relationships with adults to calm. She spent a lot of energy keeping the lid on but when it came off, she hurt people. This child clearly was not an easy child to look after. Every suggestion was met with a yes but or we’ve tried that or that wouldn’t work. There was an air that the team was ready to give up. Many had left already, including three key-carers, two life-story workers and from the original team that had welcomed her into SACCS four years ago, only two remained. This has helped confirm her belief that she overwhelms and is too much for anyone. The suggestion from the assessment was to revert to earlier stages in the plan to a time when she was making some progress. Clear indications here of a child with a disorganised attachment and that carers were experiencing feelings of being ‘helpless and wiped out’ (McMahon 2005)
The assessment discussions that followed the paperwork were rich and powerful in bringing the written material to life. Ward (2001) refers to the child’s inner world as what Freud called the ego, and what Bowlby called the Internal Working Model. He confirms that it is the inner world that is the greatest of the problems that the young people face and that in order to be helpful we need to bring about a change to this world. Ward emphasises in his paper that an assessment needs to bring about change for the child and that children needed to be able to make sense of their inner worlds. He claimed that assessment and treatment are inseparable and is adamant that assessment and treatment are dependent upon a whole group, not on an individual.
‘What matters most .. is that the whole team is engaged both in the process of assessment and in the process of treatment.’ (Ward 2004: 9)
I was able to make use of my feelings experienced in the counter-transference and was keenly aware of the possible projections into staff. Using skills of observation and being emotionally available I think I was able to feel in touch with some of the feelings being experienced by each child. I felt the depth and width of June’s fear, Bill’s watchful tentative steps of longing and Lee’s budding feelings of possibly being safe.
Each discussion, which conformed closely to Ward’s paper, in my opinion provided suggestions to help the teams prepare a plan which would continue to address the attachment difficulties still being experienced by the children.
In order to discover whether the assessment discussions made a significant impression on the subsequent treatment plans, I have looked at both the pre-assessment document and the post-assessment document for all children. I would have expected to see that strategies to attempt to improve their attachment prospects would be prominent in all cases.
Lee had no additions added to his plan in either the therapeutic parenting or life story sections. ‘Therapeutic work is potentially ongoing in all the times and contexts in which the young person is involved, and especially in the course of everyday life…’ Ward (2003: 119). Life Story is also vital in helping children with attachment issues. ‘Life Story work is a therapeutic tool that deals with the child’s inner world and how that relates to the child’s perception of external reality.’ (Rose and Philpot 2005: 15) Therapy had added an understanding of his situation and some aims to an overall plan that remained the same namely to offer ongoing weekly therapy and weekly liaison with the team.
The suggestions offered in the assessment discussions for adults at home to share the Life Story Book with Lee and to encourage him to talk about his past were not added to the plan. It would seem that the recovery team had missed an opportunity to turn the assessment discussion into a more meaningful plan.
June did have additions to the therapeutic parenting part of her plan but they tended to be in terms of description of current behaviour rather than plans for working with her severe attachment difficulties. It almost appeared that authors of the plan were complaining about the current behaviour. If attention is given to peers, she becomes jealous, fast and loud, creating situations to gain adults’ attention. There is no plan of how this could be used as an opportunity to encourage attachment. The plan offered suggestions such as to control her own behaviour and ask for time out appropriately. In one description, the child is summarised as having difficulty in her relationship with her (new) key-carer, stating that she pushes the key-carer away. A clear understanding of why this might be is not offered, neither is there a plan of what to do. Therapy and Life Story offer no update.
The suggestion to go back to an earlier stage in the plan where she had been offered care more appropriate to a much younger child had not been acted upon. In fact the plan seemed to suggest a further distancing type of care where she should be more independent and self-reliant. An opportunity to use strategies to improve attachment had been missed.
Bill’s plan did offer some ideas of how to improve attachment, with suggestions such as at bedtime Bill could be encouraged to read aloud in order to gain praise and build confidence and esteem. Suggestions were also made as to how the child could be kept in mind, and how he could be encouraged to make reparation. However, Therapy and Life Story plans changed very little.
This plan offered opportunities to build self-esteem and gave adults more ideas of how to be mindful of him, and how to encourage him to be able to make amends when things have gone wrong. This should help Bill to continue making progress in his attachments.
As two of the children have been with SACCS for several years, I looked at the pre-assessment plans to see if they were already comprehensive enough for the teams to consider that they needed no further additions. ‘A secure base’ (Bowlby 1973 and 1998:216) from which the child can explore is essential as the starting point.’ Safety, consistency and emotional closeness (James 1994) which is provided in a nurturing environment is key. ‘Without safety there is no attachment.’ (Zeigler 2001: 86) Fahlberg (1994) makes suggestions of how to encourage attachment as shown in appendix 14. Howe et al (1999) suggest that ‘People, who take an interest, who listen, care and love us, make us feel better’ and that ‘Children who successfully complete tasks enjoy raised levels of self-efficacy and self-esteem.’ Gilligan (1997) proposes that by actively encouraging positive school experiences, friendships with peers and fostering interests and talents, a child’s self esteem will be raised. Crittenden (1992) stresses that children must be encouraged to express and name and articulate their feelings in an accurate manner.
If the plans are to be effective in helping the three children to make better attachments then I would expect to see some of the above ideas in the original IRPs.
All three original plans do have many of the above ideas already outlined in them. Safety, consistency and trust with nurturing routines are expressed in all plans. Support with school, outside interests and peer group relationships are also catered for in all plans. All also encourage discussions about feelings.
Lee’s original plans are much fuller than the other plans with more detail, better understanding and more suggestions as to how to encourage attachment.
Lucy’s plan had evolved quite positively over the previous two years but had now taken a desperate turn reflecting the team’s presentation during the discussion. The original plan has several helpful strategies for assisting her with her attachment difficulties but the team were unable to take the advice of returning to the earlier plan.
Bill’s earlier plan had several dated entries below the original plan suggesting that this is a live document that gets altered as changes occur. In the overall plan the attention to encouraging attachment is addressed. He appears to be making steady progress that needs to continue.
It is interesting that the children in this study who seem to be making best progress are the children who appear to have encouraged the carers to put good plans in place. ‘It is usual for many of the interactions between mother and child to be cyclical. In such cases the responses of one partner encourage the other to respond.’ (Fahlberg 1979: 15)
It is disappointing to find that the latest IRPs do not have entries that reflect the quality of the assessment discussions. The plans already in place do suggest that the teams have a solid understanding of how to affect the growth of attachment. Yet it appears that in these three instances, additional suggestions or the reframing of the original material with the benefit of the ‘thinking’ that took place in the assessment discussion did not happen.
The question of why the discussions have not been translated into plans could be another piece of research in itself but I offer the following as possibilities. What happens during the discussions may be better at getting inside the heads of the participants than the written down plan. Or there may be some unconscious process at large which prevents the ‘thoughts’ being translated into actions. Further, there is the possibility that senior staff may be failing front line staff by not helping them to make sense of what is happening between themselves and the child during the assessment process so that teams feel stuck. Although Consultancy is available to teams it is not particularly linked to the assessment process and teams may not use it to help them explore the feelings evoked during the assessment discussions.
‘If the assessment is actually held by that external person, there is a risk that it will be taken away with them when they go’ Ward (2004: 14) With PRD being external to the team, this is another possibility.
Further thought and consideration to this dilemma is necessary, as the missing link between discussion and plan may currently be standing in the way of recovery for our children. Understanding the reasons rather than apportioning blame to teams or individuals is very important.
The findings from this section are recorded in apendix15
No detectable pattern emerged from the study it was not conclusive in suggesting or not suggesting that the assessment process is successful in bringing about recovery.
It was conclusive in that attachment is a key developmental area for our children.
In order to make sense of why I had found myself in a position of having to alter my original plans, I reflected on my feelings and thought about what they could tell me.
As I had created a state of anxiety in myself. I needed to think about why this had happened, and how I could compensate. As is usual in times of heightened stress I used my reflective journal to help me make sense of my turmoil. Intensified anxiety in anyone prevents coherent thought so I expected my writing to be disjointed and muddled. I also knew that to keep writing while feeling this way would, when re-read, probably be more coherent.
I was startled to find coming through my ‘ramblings’ that it was probably my own difficulties with attachment, separation and loss that were preventing me from planning ahead and getting to grips with the detail. In the planning stages of my dissertation, almost 9 months ago, I had identified ‘my old team’ as the basis for my study. I still had connections to some of the team and children. When the new Deputy Director of Practice was appointed, I had to hand him over the management of one of my Homes. In consultation with my Manager, I decided to move this team because I felt that the dynamic between the current manager and me was preventing her, her team and the children from making progress. I had identified in myself ambivalence towards her and that unconsciously I possibly did not want her to succeed in my place.
I found myself writing about my original ending with the team almost two years ago. I acknowledged my rage at handing over my children, my team, and my house and the feelings of deep-seated pain that were recreated were immense. I struggled to remember how my ending had been celebrated but couldn’t, I was confused. I knew the ending wouldn’t have been ignored because of the children’s needs, but I seemed to have ignored my own need to grieve. I worked long hours to avoid feeling anything. Writing in my journal put me back in touch with feelings I’d avoided.
‘Attachment behaviour is triggered by feelings of distress particularly where attachment-related issues are present…and it occurs in adults as well as children...which triggers characteristic coping styles, defensive strategies and adaptive behaviour.’(Howe 2006: 205)
I shared these feelings with my supervisor and explored this issue with him. I cried and mourned the loss, not only of the people I missed, but also of ‘myself’ in relation to them. I realised that in meeting the needs of my team and my children, I was also meeting my own. I had lost something that made me feel good about myself and it made me fearful. In my current role I have progressed to the point of ‘conscious incompetence’ (Gordon Training International 1970) I now know how much I don’t know. I am still learning how to be a Deputy Director. I represent authority and am viewed differently. Through the reflective process I have recognised the need to find a healthier way of meeting my own needs.
I had avoided and repressed these difficult feelings of anger, confusion, sadness and fear for two years. It is reasonable to suspect that I was repeating a pattern from my past. During my MA degree course, studying Therapeutic Childcare at Reading University, especially during an ‘experiential group’, I have made many links between my personal and professional life.
‘It is called an Experiential Group because the principal mode of learning involved is learning from experience and this is achieved by continually working together at understanding what happens between all of us in the group as we talk together, making connections between past and present, between family and work-place and between inner and outer worlds.’ (Howard 1998: 132)
I understand that in taking care of children who have suffered from ‘attachment’ difficulties, I am also taking care of a small part of myself that was overlooked when I was a child. My responses to separation and loss were well rehearsed and rather than feel the pain I would avoid feeling at all.
Subsequent to handing over responsibility for the home to my colleague there was a Child Protection Incident which resulted in one child being removed from the home almost immediately. It happened whilst I was away on holiday and was a fait accompli by my return. A child I will call Jan was a child whom I had brought into the company over 4 years ago, she was severely attachment disordered and she had been an extremely difficult child to look after. Jan was not well liked by staff and I had struggled long and hard to keep her, and to encourage staff to parent her. To lose Jan in these circumstances really distressed me and caused me to question my decision. I tried to avoid the feelings of self-doubt, guilt, anguish, anger and sadness. I avoided the ending completely by allowing the difficult timing to get in the way.
The loss of the MA course itself was another theme coming through my writing. The group of students and tutors has come to mean a great deal to me, we have shared many intimate moments rarely experienced anywhere else. Was this group a substitute for my old team? If so had I unconsciously ‘put off’ detailed planning of my research to avoid the ending of the group? I had already had to question my (unconscious) motives when arranging a holiday to coincide with the last two weeks of the course.
As this is not only the end of this course, but the end of all Therapeutic Child Care courses at Reading, I realise that I was not alone. The planning for the dissertation took place in the Autumn Term and all proposals were to be submitted before Christmas. However, even the tutors seemed unable to ‘push’ the students onto the final stages. The completed proposals were eventually submitted later than in any other year despite the earlier planning! This suggests a whole group resistance to acknowledging the end of what had been incredibly important attachments. ‘Most people spend their working lives as part of a group which is in itself part of a larger institution’. (Mosse 1999:1) ‘Like individuals, institutions develop defences against difficult emotions which are too threatening or too painful to acknowledge.’ (Halton 1999:12)
Finally, having lost my mother to her death just over a year ago, I realise that this topic is potentially painful. I was reminded that following a TCC study day on ‘attachment’, where we were shown excerpts from the J & J Robertson videos, ‘Young Children in Brief Separation’ (1967-1971), I was fascinated by the way in which upon re-union, a young child studied his mother’s face. I felt strongly that I probably had never experienced this with my own mother. She was at this time, at her home, dying, and being well cared for by my father. I was due to visit the same week-end and I determined to make up for what I had missed. I spent this time with my mother and really studied her lovely well-worn face. It was a wonderful experience and to be my last experience of her alive.
Whilst I have mourned my mother’s death and miss her presence in my life, I haven’t really mourned for the mother I deserved as a tiny baby. Where was that mother? I didn’t have access to her. She had been denied to me by being inadequately parented herself and possibly being depressed after my birth. Thinking about these things is very emotionally draining and it is understandable that I would want to defer having to do so. I would be forced into thinking about my own patterns of attachment and how they have affected me. Harder still is facing how I perceive them to have affected my own children in their relationships. Having identified myself as someone leaning towards an avoidant attachment, I have had to work against my own internal working model to face the pain in order to address myself to the work.
I started this study from the premise that I find the SACCS assessment process time consuming and I wanted to find out whether the time spent by myself and others was effective in helping us to achieve our ‘primary task’ which is ‘Recovery’ for our children. The children who come to our organisation all suffer with disturbed attachment patterns determined in their earliest relationship and ‘inscribed in the brain outside of conscious awareness .. they underpin our behaviour in relationships through life.’ (Fonagy 2003 cited in Gerhardt 2004: 24) This being so, it seems very important to me to ensure that reparative work offered in an attempt to ‘modify’ (Tomlinson 2004:18) the underlying attachment behaviour is of the highest quality. To this end I have studied the Recovery Assessment to find out whether as a tool it is helpful to the people who use it in enabling them to ultimately provide an appropriate alternative experience to bring about healthier patterns of attachment.
In terms of assessment, the literature I studied showed that the Recovery Assessment compares favourably with and has possibly grown out of Dockar-Drysdale’s Needs Assessment. It shares the concept of whole teams coming together not only with the Needs Assessment but also with the Bradley and Hardwick Assessment used at the Caldecott Community. Ward is also an advocate of whole team assessments ‘Since everybody is to some extent involved in the treatment, everybody needs to be involved in the assessment process.’ (Ward 2004: 11) The way that they are all conducted is also very similar with a group leader who has ‘the use of authority, based in an awareness of group dynamics and their vicissitudes in treatment settings.’(op cit: 12) It is a more compact assessment than any of the others studied and its visual representation of the child has the advantage of being immediately available to the eye. What all of the assessments lack, which has been noted in some circles, is that the child themselves are not able to make their own contribution. SACCS assessment does require the child to choose the photograph, enabling the group to see the child as they choose to be seen. Following the assessment, the resulting Individual Recovery Plan should also be shared sensitively with the child with some room for discussion. Whether this is adequate enough is probably something that needs to be thought about.
The literature on attachment confirms that unless ‘something radical happens, like treatment in particular or deeply understanding substitute care… what we are left with is a child .. who still at some level experiences the world and himself in that awful panicky state’.(Ward 2004: 19) Paying close attention to the child’s history and understanding her internal working model is key to understanding the child’s attachment model. The literature suggests that understanding the type of attachment pattern a child has developed is important in helping carers to understand how that attachment might be experienced. This might be determined in an assessment by including questions about separation or loss, or by asking how the child makes the carers feel, or by questions about whether a child panics. It is particularly important to identify a disorganised attachment in a child as this child’s core anxiety is annihilation and will impact hugely on teams. She fears contact and separation so all interactions will be problematic. How she is experienced will depend on the carer’s own pattern of attachment as the anxiety she will induce in carers will trigger their own learnt attachment behaviour. Carers may for instance react by needing to become more controlling, or by trying to please the child, whichever strategy worked for them when they were children.
As the questionnaires highlighted that a substantial percentage of staff felt that three questions were inadequate to determine a child’s score in the attachment section, I would suggest that this could be an opportunity to add to the questions in a meaningful way. There was also a comment made on the questionnaire that suggested that one person felt that those staff who fill in the assessments do not have an understanding of the different levels of attachment and that they did not recognise signs and symptoms of attachment problems. This was somewhat born out by my scrutiny of the assessment paperwork where only one of the papers examined mentioned a possible pattern of attachment.
It may be necessary in the assessment discussions for the group leader to ensure that the attachment style is always thought about. This would ensure that teams could be further helped to understand the impact of the child’s attachment not only on the child but on them as carers. Several staff in the questionnaire made reference to needing training, or if already in receipt of training that they required more. Attachment training is in the SACCS training programme but not until well into the second year of employment, so other opportunities need to be sought to ensure that attachment is understood.
It may be that Attachment is so important as the basis on which everything else is built that it needs to be taken right out of the six developmental areas and be entirely separate. If the child’s attachment needs aren’t met then the other developmental areas are very unlikely to develop either. ‘The type of attachment at 12 months predicts frustratability, persistence, co-operativeness, task enthusiasm, social competence, self-esteem, empathy, and classroom deportment.’ Stern (1985: 187) Someone has made a comment to this effect on the first question of the questionnaire. If encouraging attachment is our main task then maybe it should be the main focus of the assessment.
What was so striking for me in the assessment discussions was how I ‘felt’ the impact that the children were having on the teams. Stepping back slightly from my usual role, I was able to feel it in a different way. Focussing on these particular assessments has meant that I have had to be more aware of my own feelings than I probably normally would be. I have had to continue to consider my feelings and the assessments for a much longer time-scale than is normal. I also recognise as discussed in my personal reflection that I have grown emotionally in the last two years and it may be that I am more emotionally available to feel what is going on. However, I am struck by the failure to translate rich discussions into good plans and wonder whether teams have been helped enough to link the child’s attachment behaviour to how they feel when they care for the child. I am reminded of Lee’s carer who was off sick with stress due to being targeted by Lee, and June’s list of casualties who had fallen by the way side in trying to meet her overwhelming needs.
The assessment process is necessarily child focused but is enough attention paid in the process to supporting the adults? There are structures set up elsewhere for this support to happen such as in supervision that is offered to all staff fortnightly and fortnightly team consultancy. Weekly team meetings normally last about three hours. The training programme is also I believe second to none. However, I wonder how well all of these support systems join up to create a ‘holding environment’ (Winnicott) that is ‘good enough’ to contain staff who come to us with their own attachment histories. Key-carers are particularly vulnerable and everyone needs a thorough understanding of how to support them in their enormous task. Perhaps PRD and DD should meet following the assessment to consider what has happened during the assessment for the team? At this point I can offer no recommendation other than that this is thought about both in the PDR and at Regional Directorate level.
A final thought from Ward (2004: 13) who advocates that the group leader in an assessment needs to be a senior person with authority of knowledge, experience and insight but who should not be external to the team. He is concerned that if an assessment is held by an external person, that there is a risk that it will be taken away with them when they go. I think that this may be something that may be worth thinking about.
Assessment appears to be important not only in the gathering of information but in making sense of it. It has been possible to show that information can be gathered from several sources. All of the literature that I have consulted has emphasised a thorough investigation into the child’s relationship history, not only of the child but of the parents too. Observation of current behaviour when set in context of their history may begin to make sense. Close attention to the way a child reacts and responds to situations will provide clear evidence needed for assessment. This can be collated in assessment paperwork such as I have examined for this study.
Once the information is collated, a process for making sense of it does seem to be an essential aspect before being able to make plans for future care. My study has shown that a collective discussion using the paperwork as a starting point with people open to whatever feelings are being evoked may provide rich information for further discussion. Assistance in making connections appears to be another is necessary ingredient. I have also found that support for the people doing the front line work is crucial when expecting them to attend to the complex needs of our most vulnerable children
In order to draw this study to its conclusion I need to return to my original question that is ‘Does the SACCS assessment process contribute to the recovery of children in the area of attachment?’
To answer that question, I have made a comprehensive study of the literature, both in the areas of attachment and assessment. I have undertaken a small-scale survey of staff who use the assessment in order to canvas their opinion and find out whether they think it is effective. I have taken part as a participant-observer in three Recovery Assessments and I have reviewed some collected data. Through this process I am now in a position to draw together what I have found and make some recommendations not only about the assessment under review but about assessment for treatment in therapeutic childcare as a whole.
The SACCS Recovery Assessment has the potential to contribute to the recovery of children in the area of attachment. It compares very favourably to other assessments for treatment that I have studied both in this specific area, and more generally. It is considered overall to be user friendly, with understandable questions and a clear scoring system. The staff who use it find it useful in identifying attachment difficulties and find that it leads them into discussions which provide helpful interventions.
It appears that staff have some understanding about attachment theory, and are able to understand the importance of a child’s earliest experiences and the resistant nature of the ‘internal working model’ (Bowlby 1969). Assessment discussions that I attended were rich and suggestions for interventions were offered. At the last hurdle, there was evidence to suggest that an assessment does not always lead to an improved treatment plan. However, it must be remembered that all of the pre-assessment plans did show evidence of good understanding of ways to encourage attachment.
One area highlighted by staff where improvements could be made, was in the amount of questions asked. Three were considered to be too few to determine a child’s pattern of attachment. I would concur with this from my review of the literature, and add my support to staff being able to identify the different patterns of attachment. Staff need to be prepared for how the child might impact upon them. I was confirmed in this opinion by my attendance at the assessment discussions and my subsequent reflections upon the discussions. I believe that there may be a correlation between adults not fully understanding the impact the children are having on them and the plans not being updated.
I would recommend that consideration be given to the following:
The Attachment Section of the Recovery Assessment is removed from the six reportable developmental areas that are represented by the spider graph and is viewed as an entirely separate section. The importance of the child’s internal working model has already been acknowledged in the Summary of the Assessment of the SACCS Recovery Assessment and refers the integrated services to the appendix where this term is defined. An extension of this could include defining the child’s pattern of attachment with a helpful short guide to i