Podcast Episode: Why attachment matters
What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.
HM - Helen Minnis
DW - David Woodier
In the following interview between Professor Helen Minnis, from University of Glasgow, and David Woodier, a teacher, adoptive parent and blogger for Scottish Attachment in Action, Helen speaks about why attachment matters to her. Themes emerging from the interview may well resonate with those living and working with children and young people who have had an adverse start in life.
DW My name is David Woodier. I am a teacher; I have looked after children and I am here today to interview Professor Helen Minnis about her work and her research and I am doing this on behalf of Scottish Attachment in Action. Helen is there anything you would like to say about yourself before we dive into the questions?
HM No, just that I'm very enthusiastic about Scottish Attachment in Action so I am delighted to be interviewed.
DW We appreciate very much your work. When did your interest in attachment begin?
HM I wanted to do psychiatry, but before I wanted to do psychiatry I wanted to travel so I spoke to Ed Taylor who, at the time, was the Head of Department of Child and Adolescent Psychiatry at the Maudsley, and said, "I'm going to Guatemala for a year to work in an orphanage, what would you suggest I think about?" And he said, "You should think about attachment and attachment disorders'" and he gave me the draft of the psychiatric classification system for attachment disorders, which was literally still in draft because this was 1992, and said, "just think about that while you're there." And that was where my interest was born because that draft talked about children, on the one hand, who had been abused and neglected, being indiscriminately friendly, and on the other hand, some of them being withdrawn and failing to seek comfort, and I arrived at this orphanage in Guatemala and just saw that right in front of my face. I was literally covered in children under 5, I couldn't walk forward until I had pealed the little hands off and I realised that they were on to something and I just became passionately interested in it from that moment.
DW Is Scotland a nurturing place for children to grow up in? are children able to build healthy attachments here?
HM I think it's all relative. So, I think Scotland is trying very hard and I think the Scottish Government has done a lot of really positive thing over the last few years. I mean, I remember a few years ago there were big billboards that were paid for by the Scottish Government, for example, with a sponge, a big sponge, saying, "This is your baby's brain." And lovely adverts on local radio saying, you know, "Have fun from day one." So, in terms of encouraging the public to think about attachment, I think actually the Scottish Government is really quite far ahead. I also think that we realise that we've got some really big problems and I think one of the big problems we have is the way we treat our teenagers, oddly enough, I am quite interested in teenagers because I think we ignore them, we don't give them eye contact, we don't give them a role in society. So, I think there are some really major things that we could be doing to make Scotland a more nurturing place, but its great to live and work in a country where, you know, that's the moto and that's what we are aiming for.
DW When did you first become involved in the work of Scottish Attachment in Action and why does an organisation like that need to exist.
HM Well I was involved from day 1. We had had a little, I am trying to remember what it was called, we had something called the Attachment Reference Group, that had been going in Glasgow for a few years, where we invited multi-disciplinary colleagues to come along and discuss attachment, maybe 3 times a year, we were always oversubscribed and I think it was through that, I think Edwina Grant and a few other had heard about what we were doing and they were thinking along very similar lines, so they organised a day where a facilitator came along and there was quite a big group of us and we just had a brain storm about what Scottish Attachment in Action should look like, and it was just an incredibly exciting day because we discovered that even though we were from such different disciplines, we were really talking the same language and I think what we realised was that there was a need for a common language about attachment across, particularly across frontline services who work with children, and that needed to include all frontline services, including the police and teachers and nursery nurses. So, there was a role for both training and advocacy and I think Scottish Attachment in Action has always really tried to sit in that space, and I think it's going to always be needed because I think getting people to think about young children is always tricky.
DW Why is that?
HM Do you know, I think it's very simple. I think as adults, well we know that we tend to see people that are like us, we tend to kind of understand people that are like us and so we are adults, it's a long time since we were children, I think it really is as simple as that, I think it's very, very hard for adults to put themselves in the mind of a child and it's something that needs to be a daily struggle I think.
DW A number of years ago you looked at the mental health of a group of adopted children living in Scotland, what effect does nurturing, care and a stable family life have on a child who was, perhaps, maltreated early in life?
HM I think it makes all the difference. I think adoptive parents have always known that and I remember being sharply told off many years ago because I used the word 'natural parents', which was an old term that people used to use for birth parents, and someone said, "but adoptive parents are natural parents because they've done the nurturing", and I thought, God, that is so true. But now we know that it is actually much more biological than that so although, you know, a child comes into the world with their genetic hand of cards, what happens with that genetic hand of cards depends so much on the nurturing that they receive from their family. So, we know about epigenetics, for example, we know that the environment that surrounds the child can actually modify your DNA and we know a lot about the way that the brain develops and how nurturing from parents, particularly, is just so crucial.
DW So if we could look inside a child's brain, a child who has suffered maltreatment early in life, could you be any more specific about, what are some of the differences that nurturing can make?
HM Well, I think we don't know more than we do know, I think the brain is still a kind of unexplored landscape really. You know, I think one of the reasons I'm in Child and Adolescent Mental Health is that I actually think we know less about the brain than we know about the universe, you know? So there is a huge amount to learn but, for example, we know that the frontal temporal lobes of the brain, that's the kind of stickie out bit in the forehead, that's the bit of the brain that makes our brains different from our ape cousins, and they are bigger in humans and that's because we need more in terms of planning and social interaction and a lot of that, we think, is kind of located in the frontal temporal lobes, and we know that children who have suffered early neglect and maltreatment sometimes can have problems with some of the functions that are particularly associated with that part of the brain and we think that one thing that nurture and care can help with, for example, is to help children to inhibit some of their emotional responses so, for example, to put a bit of a break on their emotional responses, and also just to really learn the importance of plugging into other special people, and I think, again, that's something that you learn through being part of a family and, you know, being kind of, having the world kind of interpreted for you through your parents and your older siblings and your grandparents, those kind of people.
DW There are some children who seem to be harder to reach, they seem to resist kind of connecting with that nurture and care. It's harder for them, perhaps, to receive that love, is there anything from your understanding of how children build attachments that could help us reach out to those children?
HM One of the things that we've become more and more interested in is in what I have heard called faulty signalling, which is where neglected children, I suspect, just habitually have kind of, because of their early experience of neglect, have kind of learned to manage their own world, so they just habitually don't reach out to parents and carers and they fundamentally don't understand that that's what parents and carers are for, they are there to help you and to support you and comfort you when you are stressed. John Bowlby, who developed attachment theory in the beginning, really described how right across species it's an instinct, it's a profound instinct to reach out to your carers when you are stressed or cold or frightened or have a tummy ache, or whatever, and we see, and luckily it's actually a really small minority of abused and neglected children, but we do see some children who just don't do that, they just don't reach out, and if you think about what we have just been saying about how important plugging in to special adults is, then these children are really missing out on huge waves of normal development. So, one of the really fantastic things that we see is that usually, and I mean I'm guessing, nobody knows for certain, but I would say 99 times out of 100 if neglected children are placed in loving families soon, you know, early in life, that lack of signalling just disappears, it just melts away quite quickly. But there is a tiny minority of children where it doesn't melt away and I don't know whether that's something to do with the constitution of the children themselves, or whether it's to do with not having the opportunity to be placed in a loving, nurturing family soon enough, or what, there is a lot we still need to know about that, but there is a tiny minority who, even in the teenage years, and probably in adulthood, still just don't quite get that they should be reaching out.
DW I've noticed that some children with difficult starts in life, children who don't seem to respond so well to nurture and care, perhaps, from a foster carer or adoptive parent, somewhere in adolescence they appear to kind of sort things out, there seems to be a shift, and I was just wondering from a kind of a more medical, scientific point of view, is there a way to explain that? Is that a correct observation even? Is there something going on developmentally in their brain?
HM Well we know that there are 2 really, really rapid periods of brain development in life, the times when, there are 2 times when your brain is just doing most work and that is in the first few months and years of life and then again in adolescence. What's happening in adolescence, particularly, is you're, the axons of your brain, so the kind of long connections between your brain cells are being cladded, so they are getting what we call sheaths, but it's a bit like cavity wall insulation, I think, and this is not something that I am an expert on, but I've heard it used as perhaps an explanation for why you can have a really articulate 9 year old son, who suddenly gets to the age of 12 and suddenly seems to lose the power of speech. There is a lot going on in the brain that they are kind of concentrating on. But I think it's pretty well recognised that is also a time of opportunity because there is so much, well we talk about plasticity, but there is so much of an opportunity for change and new development in the brain and one of the things that always gives me hope is that we now know that you can develop new brain cells, even in old age, so the brain is quite a different, it's a different organ from other organs in the body in that when you are born your heart looks pretty much like it's going to look as an adult, and the same with your kidneys and your adrenal glands, they are just kind of small versions of what they will be as you grow up, but that's not true of the brain, the brain when you are born, and then again in adolescence, had a huge amount of sculpting still to be done.
DW it's an opportunity for change, it's an opportunity for healing and recovery even.
HM Absolutely. I think it's worth remembering that some people heal and recover even later than that, you know, and I've got lovely stories of, personal stories of adoptive children who have left home at the age of sixteen and said, "I'm never going to darken your door again," then they turn up back again later. I've got a family friend that that's true of and, you know, he came back at his adoptive mum's 70th birthday party, hadn't been seen for years, covered in tattoos from head to toe, had been in prison, and he is now a very loved member of the family again. So, you know, although you are right that the teenage years is a real opportunity, there are later opportunities too.
DW Here in Glasgow you have been piloting something called the New Orleans Intervention Model...
HM That's right.
DW Could you say something about what this model is about and how it's different to services as usual for children and families?
HM So the big difference, I would say there are two big differences, one is that it's an infant mental health model, I will tell you about that a bit more in a moment, and the other difference is that it offers treatment to birth families so that it's not simply an assessment model and it was developed by Professors Charlie Zeanah and Julie Larrieu from New Orleans, from Tulane University, and for a long time in New Orleans, every child who was under the age of five who came into an episode of foster care, was offered this model. Basically what it does is, it offers very standardised attachment based assessments of the child in each of their care giving relationships, so if you had a child, for example, with two foster carers and two birth parents, they would come into the clinic four times for these assessments, and they also do interviews and questionnaires with the birth parents about their own experience of attachment and care giving, and they refer the birth parents for help so, for example, if they have got problems with substance misuse or domestic violence, they would get referred on. That process takes about three months and then there is a period of quite intensive treatment, with the aim of changing the birth families' relationships enough that they can get their child home. But if it doesn't work within a time limit then the child is recommended for adoption. So, the idea is to give a high-quality intervention and trial of treatment with a view to the child going home or adopted, if that's not possible..
DW Has any aspect of the study, so far, surprised you?
HM I think we have learned a lot about the nature of our systems, about the ways in which we inadvertently cause delays for children and, actually, I think it's got a lot to do with what we were talking about earlier, it's got a lot to do with our difficulties, as adults, in putting ourselves in the mind of the child. So, there are so many places through a child's journey, where adults, adults from all sort of professional backgrounds, could have thought, this is not right for this child, we need to move this forward, and we don't. So, that's, it's almost not been a surprise, but it's been a surprise at just what a perennial and entrenched problem that is.
DW What kind of benefits have you seen from you pilot of the New Orleans Model?
HM Honestly, I think it's too early to say because what we see, from the feasibility trial that we have done, is that there are pros and cons of the infant mental health approach and the social work approach and it's just, come back and ask me again in 2020.
DW Would there be a benefit in Scotland if we followed the example of some parts of the United States where foster carers are also recruited to become prospective adopters? I'm thinking here about reducing that delay, or the number of families that a child moves to.
HM Well one of the things we've become really interested in, in this project, in fact so much so that we have actually got a PHD student focusing on this, is the nature of foster care. One of the things that Mary Dozier from Delaware has talked about a lot if commitment in foster care, and one of the things we are really exploring is whether commitment is something that comes from the length of a foster placement or whether it comes from the, kind of, freedom that's given to a foster carer by their managers to, kind of, fall in love with the child. In the states now, and it is pretty much true across that states I believe, foster carers are usually jointly registered as adopters, and I think the philosophy behind that is that foster carers are really supposed to be totally child centred so that, you know, the idea is that they are supposed to love and commit to the child and basically be potentially the child's forever parent, but if the birth parent gets themselves back on track then they will have to relinquish that child. What people have often said to me is, my goodness, that must be awful for the foster carer, and then you think, yeh but can you imagine that that's generally what we do to children? So, in a sense, that system allows the adults to take the hit and it seems to work well because, certainly in New Orleans it does seem to reduce delays and it also means that you are not kind of building in a loss for the child.
DW It's still a reality, however, in the UK and in Scotland, that children who are looked after are often moved around. They experience new foster parents, new schools, new teachers, new social workers. How do we help children who may form multiple attachments, for example, should a child who become adopted visit their previous foster carers? Should a young person who is unexpectedly moved to a new school over the summer be given a chance to go back to the old school and say goodbye to a teacher?
HM Well, I mean, I think that those are example of attachment in action and I think, again, they are example of being child centred so, you know, in a family where there has not been disruption that has come through abuse and neglect and placement moves, that's what you would do for your child, you know, I think my daughter at the age of 4, for various reasons, had to move nursery quite quickly and, you know, we made a goodbye cake and we went and visited everyone and, that's what you do because you nurture your children's attachments. I think it's about nurturing children's attachments and recognising that secure attachments can come from surprising places and that, you know, a child who has had a difficult early start may have a secure attachment with their Primary one teacher and that's got to be recognised.
DW Maybe this question kind of says the same thing but, I'm voicing concerns that I hear from teachers and adoptive parents and foster carers, some people are concerned that that contact, for example, with a previous foster carer, will prolong a child's sense of loss and it might make it more difficult for the child to form an attachment to a new family.
HM I mean, I think these are really difficult questions but, I guess probably the most important thing is to try and tune in to the child, try and understand that a child is likely to be grieving, you know, that children go through bereavement processes in the same way that adults do, but that relationships do shift for children, em, and that that's not a reason not to, it's not a reason to pretend they don't exist. I mean, I think a relationship with a past foster carer where it has been made clear to the child that they are now in a forever family, that this is the new family, this is the family that are going to be committed to you for the rest of your life, but the foster carer that you lived with previously still cares about you and would like to see you or be in contact from time to time, that strikes me as positive, very, very different from a situation where you have, for example, quite a damaged birth parent, for example, and I'm not suggesting that all birth parents are damaged, sometimes this can work well with birth parents too, but if, for example, you had a birth parent where the experience, for the child, of visiting that parent is really traumatic, then that needs to be thought about too and, again, it needs to be thought about in a child centred way. You know, and sometimes difficult decisions have to be made and, you know, children have to not be allowed to see people who have a negative effect on a development.
DW Children with attachment difficulties often struggle to get the right kind of support, like support in schools, for example. Can you talk about some of the reasons for this? Is it because attachment difficulties can present in so many different kinds of ways that it's hard for teachers, it's hard for schools to clear identify them?
HM I think there is a lot in that. I think identify, identification is a problem and I am going to tell you about that in a moment, but before I get onto that, I think you are absolutely right, children with attachment issues, particularly if they actually have attachment disorders, nearly always have other problems and I think that really is confusing. It's not just confusing for teachers; it's also confusing for parents and clinicians as well. So, we know now in child and adolescent mental health, something that we didn't know 15 years ago, which is that if you have one child and adolescent mental health problem you are more likely to have others. So, we used to say, "oh you've got ADHD so it can't be anxiety." We now know that was not very sensible at all. Children with ADHD are more, are at a higher risk of also having, for example, problems with autism or vice versa. Children who have experienced early neglect and abuse are at higher risk, than the general population, of having these other neuro developmental problems and this is in some data that we've found. Other people have found this too, that children who have had early abuse and neglect, who have mental health problems, often have quite complex neuro developmental problems, and I think that's really hard for people to get their head around. How can these problems be identified in schools, that's really difficult. I would say, on the plus side, educational psychologists in Scotland, I think, are really on the ball with this, you know, I think they have led the way in thinking about attachment in schools and helping teaching staff to think about attachment. We're in the process of developing something, trying to develop something called the School Attachment Monitor, about a decade ago we developed something that we called the Computerised Manchester Child Attachment Story Task, and it was a computer game that was based on the Manchester Child Attachment Story Task, which is a kind of doll play story stem way of getting into the way young children think about their relationships, and that had to go on ice for a few years but just in the last 6 months I have been working with Steven Brewster and Alessandro Vinciarelli, from Computing Science at Glasgow University, and we're trying to develop SAM, which will be like the Computerised MCAST, but if it works it will also be automatically rated, which means that it could be used in schools so we could, basically, look at the profile of attachment in school children and in classrooms and we could see how we are doing in schools. So, we are trying to contribute a little bit but I think there is a long way to go.
DW Foster carers, adoptive parents, social workers sometimes express frustration with mental health services, is there a miss-match between the needs of some of our children and what is offered to families, is there something we can do about that?
HM Well I think sometimes it's a problem of not recognising the complexity of problems that children experience when they have been maltreated. I mean, I've got a lot of sympathy for many of my colleagues, many of my colleagues do recognise the complexity, but I think we have all been on a really steep learning curve. So, we've done some research recently which suggests that the kind of direction of travel may not be what we thought it was. We know that a lot of ADHD, you know, has a lot of genetic causes, but I had always thought that another route into ADHD was maltreatment, but it's starting to look, from some of the data that we've got recently, that it might actually be the other way around, that children with some of these neuro developmental problems, in families who are already struggling, might be more likely to be maltreated. So that, in a sense, many maltreated children have a double whammy and I think this is new information for child and adolescent mental health services, I don't think we had really appreciated that, that, you know, in the past we used to see children who had been maltreated and we would think, well no wonder they are, you know, they've got conduct problems or whatever, you know, they have got problems with behaviour, when in fact we maybe should be thinking a bit differently. We should be thinking, we need to really assess these children carefully because it might be that they've got a kind of genetic loading towards some neuro developmental problems that are going to make them more difficult to look after in the first place, not that that's ever an excuse to maltreat a child obviously, but I think the understanding and the complexity of these children just, you know, it hasn't been there in our profession and we are getting there. But the other big issue is, there are just not enough of us, I mean, the honest truth is there are just far too few child and adolescent mental health clinicians. So, I think if there was something that parents could do as lobby, I mean my clinic colleagues are genuinely overwhelmed..
DW You've also been looking at the feasibility of DDP.
DW Dyadic Developmental Psychotherapy, as a treatment for maltreated children in the UK. What is it about DDP, compared to other approaches, that makes it worthwhile, considering the relatively high financial cost?
HM I think it's worth considering because I think it's different from existing, kind of, psychotherapeutic interventions for children who have experienced abuse and neglect, in that it really tries to promote what Mary Dozier talks about, she calls it gentle challenge. So, kind of old fashioned psychotherapy is very much led by the child where, you know, basically the child leads what's happening in the room and the psychotherapist follows, now that is very sensible for a great majority of children, but if you've got children who don't signal their needs then that's maybe not going to be as successful, and so what I like about DDP and what I think really gives it potential is the idea of pace. So, it's playfulness, acceptance, curiosity and empathy, and the kind of pace stance is a bit more gently challenging, you know, you are not letting the child get away with just hiding under the table and not engaging in therapy. You are going to be, in a playful, accepting and curious way, saying, well, you know, all of the things that happened to you in the past, that's probably what's making you sit under the table and you've got these good parents here who are ready to give you a good snuggle, so come and, come and experience the love that's available for you. So, it's a bit more directive, in a gentle way. We also know, from our research, that therapists that are using it are generally very, very enthusiastic. So, I think it's got a lot of potential and I think it really, really needs a trial.
DW What are the barriers to seeing...?
HM One of the things I think the NHS should be really proud of is that we carefully review the evidence base for out interventions and, unfortunately, we haven't yet got a very robust evidence base for DDP. We really need randomised, controlled trials if it's going to be able to be commissioned, you know, if the NHS is going to take this on and roll it out they are going to have to have robust evidence base, we need those trials. We are putting in an application the middle of next year, you know, we are crossing our fingers about..
DW Over the last ten years, is it fair to say there has been somewhat of a resurgence of interest in attachment, particularly in Scotland?
HM Oh I think so, I think so. It's very much a sort of double edged sword. I was at a meeting a couple of years ago, in England, with lots of social work and academics, I think I was the only child and adolescent psychiatrist, and people were saying things like, "oh, you know, all this early stuff and all this attachment stuff, it's kind of flavour of the month," and I'm thinking, sorry? So, you know, there are, in some circles, I think people don't quite see the importance of it, but again I think that's one of the reasons why I'm really happy to be living and working in Scotland because I think, I think it has kind of got into the, I think we have developed a shared language. I think Scottish Attachment in Action has to be patted on the back for that, but I think there are other groups that are really working towards a much more nurturing place to live, I mean, for example, I think it's absolutely wonderful that in education, I mean, I have this whole idea of how nurturing is our school, and the idea of nurturing schools and just the understanding that a nurturing place isn't a kind of wishie washy place or, you know, a kind of soft option place at all, but that if we are nurturing then children can thrive and that they do well emotionally and behaviourally and they also do well in terms of their attainment. So, it's a bit of a no brainer really.
DW What would it take to put attachment into action even more in Scotland?
HM I think we just have to keep harping on about it, I think we have to realise this is not flavour of the month, this is, attachment is a fundamental instinct that allows children and young people to plug into what they need for their development and there is a reciprocal care giving instinct in adult to respond to that and that's the glue that holds our society together.
DW Don't you think that there is also difficulty in that attachment can remain too much kind of theoretical or abstract and, actually, but actually to get it to change the way we make decisions in our legal system, the way we work with a child who is very disruptive in a school and is being threatened with exclusion, that actually there is something that we don't understand or we underestimate in terms of the difficulty of actually putting some of what we know about attachment into practice?
HM I think there really is a problem with, as you say, the fact that attachment has been very laboratory based, I mean, there is a recent nice guideline on attachment and, I think, unfortunately, and this is not a criticism of the people who wrote it at all, but, for example, some of the measures that they recommend being used in clinics, no one is going to use them because they are too cumbersome, because they are laboratory measure, you know, for example, the gold standard measure of attachment in young infants is the strange situation procedure, now I think that's probably the most important scientific advance of the 20th century, however, it takes 2 or 3 people about 20 minutes to actually do it and that's, you know, not in addition to the set up time and then, you know, it takes about an hour, an hour and a half, to rate, someone has got to go to Minnesota to get the, it is not feasible on the NHS. That's one of the reasons that we are developing, trying to develop better tools with SAM, for example, you know, we really want to develop things that are quick and easy. I think in terms of actually intervening with children in schools, in families, it's about trying to translate the learning that you've got, from the research, into practice and I think things like, how nurturing is our school, is phenomenally important because if you've got teachers who understand the roots of children's behaviour, it's actually going to change the ethos of the classroom. So, I wouldn't underestimate the importance of talking about it.
DW Helen thank you very much for your time and for these very interesting answers you've given and, again, how much we appreciate your research and your work and your advocacy for children and young children in Scotland, thank you.
HM Thanks very much, been a pleasure.
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