Family Futures Consortium


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	Family Futures have developed a Multi-Treatment Approach to helping children with attachment difficulties and their parents.

UNLOCKING THE PAST

A Multi-Treatment Approach

The primary task of parents today who foster, adopt or are caring for children with attachment difficulties, is to help the child recover from their early experiences and to form positive attachments. This often presents a considerable challenge for child and parent.

The child's early experience of relationships may have involved illness, separation, loss, neglect, abuse or multiple carers. This makes it hard for such children to trust and to relinquish control. They bring with them patterns of behaviour that may have been adaptive and enabled them to survive in the past, but are inappropriate in the context of a caring family. Contact arrangements, if not properly planned and supported, can add to the complexity of forming new attachments for everyone.

Many parents have found that conventional approaches to helping their families are inadequate and lack an understanding of the particular issues that fostering, adoption, step-parenting or parenting a child with attachment difficulties raises. Family Futures have developed an approach to helping such children and their parents or carers cope with these complexities. An integrated multi-disciplinary treatment approach is required.

OUR APPROACH

This is based on the following principles:

That a new family is the most important resource a child has, and all therapeutic work should seek to build and strengthen the family relationships
The traumatic effects of a child's early experiences remain unexplored and inaccessible to them. As a consequence, they defend themselves against painful feelings and act out experiences that they are unable to understand or verbalise
That change is possible if parents and children are helped to work together to understand their pasts and form positive attachments in the present
The role of the therapeutic team is to facilitate this process and provide on-going support.
Therapeutic help for families who foster or adopt children with attachment problems needs to be intensive and long term.

THE AIM OF THE PROGRAMME

To address directly and change the child's attachment patterns
To incorporate a holistic approach which integrates all treatment approaches: psychological, psychiatric, neurobiological, educational, dietary and paediatric
To increase parents' confidence and parental skills
To incorporate the extended family and professional support in maintaining positive changes
To provide ongoing support to the family, as appropriate

THE KEY AREAS COVERED BY THE PROGRAMME

Overall, the Attachment Programme is designed to address the complexity of contemporary placements. In order to do this, the programme has eight essential elements which are dealt with simultaneously, these are:

The child's early history and patterns of attachment
The parents' relationship as a couple and their expectations of themselves and of each other as parents. For single parents and carers: the impact of current or previous relationships.
Contact with birth relatives and siblings
The current behaviour difficulties displayed by the child at home and/or at school
The parenting strategies used by the parents to deal with the above difficulties
Patterns of interaction and communication as a family.
The neuro-physiological, medical-psychological and educational impact of early trauma, which are dealt with holistically
The management of the wider family-support network, including the extended family members, schools, social services and significant others.

In our experience, in order to achieve any significant change in children and families coping with the complex issues encompassed by adoptive or foster family life, the complexity has to be acknowledged and all eight elements need to be addressed. This may require a concerted and intensive period of intervention, involving family members, for up to five days. With this approach, it is possible to achieve a sufficient momentum for change to reverse the negative spiral in which many families in crisis find themselves. Ideally, families should participate in the programme during the first year of a permanent placement. However we can also work with children in short-term placements, to prepare them for a new family and also with families who have been formed many years prior to referral.

The follow-up programme is designed to maintain and build upon the positives gained during the intensive week. Our standard follow-up is a tailor-made programme of at least two years' duration which will include Theraplay, sensory integration therapy, nutritional programmes, intensive parent mentoring and school based interventions, alongside therapeutic family based work.

Family Futures do not use therapist holding of children or other intrusive forms of therapy.

Holding Therapy & Other Intrusive Therapies

Family Futures Position

During the early 1990s Alan Burnell was working as a Counsellor at the Post Adoption Centre in London. During that period, the population of parents approaching the Centre for help shifted from a majority of parents who had adopted their children as babies to parents who had adopted older children and sibling groups, the latter being more representative of the contemporary adoptive family. The children in these families were displaying more extreme forms of challenging behaviour, for example lying, stealing, verbal and physical abuse, self harm and depression. In discussion with PPIAS (now Adoption UK), Alan Burnell took the lead in establishing a forum for discussing this group of families with researchers (David Howe, Alan Rushton), other practitioners and adoptive parents representing PPIAS. One of the conclusions reached was that conventional counselling, family therapy or individual child psychotherapy appeared ineffective. It was concluded that even a specialist agency like PAC was more than often 'too little and too late'. The families seen at PAC at that time were often at the point of breakdown. Parents and PPIAS wanted more practical and strategic help as well as more effective therapies.

Some parents, because of their desperation at the lack of services in the UK, went to America to the Evergreen Attachment Centre in Colorado and themselves paid to take part in a two week intensive programme. Some parents because of this contact, joined the American Association for Attachment Therapists (ATTACH) and attended their annual conferences.

In 1994, Alan Burnell convened a one day conference in collaboration with PPIAS called 'Make or Break'. The aim of the conference was to bring to public attention the difficulties adoptive parents were facing. Many parents spoke honestly, openly and very movingly about the challenging behaviour they had to confront daily from children placed with them who clearly had severe attachment difficulties.

As Director of the Post Adoption Centre, Alan Burnell attended one of these conferences with Caroline Archer and Beth Gibb from PPIAS. Subsequently Greg Keck and several other attachment therapists were invited to the UK to discuss and demonstrate their attachment based therapy.

The fact that Reactive Attachment Disorder was included in DSM-IV and attachment therapies had been developed (albeit in America) gave many families hope. They no longer felt that they were to blame for their children's difficulties and became optimistic that therapy designed to help their children would soon be available.

Hitherto, adopted children's difficult behaviour had been attributed to either poor parenting on behalf of the adopters or 'genealogical bewilderment' and identity crisis. What became apparent from the contact with American therapists was that failure to form secure attachments was responsible for much of the subsequent behavioural difficulties in adopted children. The 'cure' was to use a therapeutic approach based upon attachment theory. This had been pioneered in America by Foster Kline. His 'rage reduction' approach represented a developmental re-enactment of the child's infantile rage resulting from the birth parents failure to meet primary needs. The consequence of this failure was the child's loss of trust in adults and carers to meet their needs, leading to excessive self-reliance and controlling behaviour. A key element in these rage reduction attachment therapies was therapists holding the child or 'holding therapy'. This element was very controversial at the time and still is today. The premise for this technique was that the therapist would induce a state of rage and resistance in the child, which the therapist would hold them through until the child regained a sense of calm and equilibrium. The child would experience this as a loss of control but one in which they were kept safe and were 'forced to be dependent' and experience 'safe dependency'. There were other strands to this form of attachment therapy, such as parenting strategies, therapeutic respite and life story work.

From its inception Family Futures has never practiced or propagated therapists 'holding'. Though we acknowledge that we were instrumental in supporting the application of attachment therapies and of dialogue with American attachment therapists, we never accepted the 'rage reduction' intrusive therapy approach. We did find other aspects of the therapy and the theoretical rationale helpful and informative. Our primary objection to therapist 'holding' was that it impinged the rights of the child and was potentially dangerous and re-traumatising. The staff of Family Futures at our inception believed that 'attachment difficulties' in children that were adopted emanated not just from the failure of the primary attachment to the mother in the birth family, but that attachment difficulties in the child were symptomatic of the impact of early trauma on the child's emotional, physiological and neurological development. We put trauma rather than attachment centre stage. Our therapeutic approach is focused on, in the first instance, enabling the child with the help of their new parents to integrate early traumatic experiences. The primary conduit for therapeutic change we believe are parents, not therapists. The therapist role is to facilitate trauma resolution in the child and secure attachment behaviour in the chid and parent. Our work in this field has been influenced by Van der Kolk, who now talks about Developmental Trauma Disorder for children with repeated early trauma. Dan Hughes and his use of Dyadic Therapy has also informed our therapeutic work with children. Neuroscientists such as Alan Schore and Jaak Panskepp have provided a theoretical and research base for our understanding of the development of the brain and the child's emotional world. A key concept in this approach is 'affect regulation', which requires trauma resolution and developmental re-parenting in order for healthy attachments to develop. This dual focus underpins our belief that therapeutic services for adoptive families should be a collaboration between professionals and parents. During the therapy we now use Theraplay to address attachment issues when the focus of intervention moves from trauma to attachment.

A more recent development in our practice has come about because of our pioneering research into Executive Functioning in children who have experienced early trauma. We are now convinced that early trauma, not only effects the developments of attachment, but the development of synaptic pathways in the brain. Trauma impoverishes and impairs the development of these pathways, particularly to the frontal cortex which is the 'Executive Function' provider for the brain. Failure to develop this capacity leads to problem-solving difficulties as the child develops because of impulsivity, poor working memory and poor strategic planning. Traditional attachment therapies developed in America portrayed the attachment disordered child as oppositional and controlling. Though this characterises some behaviours in children who have experienced early trauma, we now see the long term effect of this, more in terms of the impaired ability to problem solve in novel situations. This represents a fundamental shift from perceiving the child's problems as emanating from 'won't do' to 'can't do'. A systematic and empathetic programme of strategies designed to help the child become self-managing has become a new dimension to our approach.

Care and Control: Policies and Practice

Two of the longer term impacts on children of repeated early trauma are:

Poor impulse control resulting from impaired frontal cortex development
Re-enactment of unresolved early trauma.

The consequences of these two impacts of trauma on child development are impulsivity, poor problem solving, 'fight/ flight or freeze' behaviour, and a propensity for aggression and abusive behaviour which represents the re-enactment dimension. Children displaying these behaviours are prone to become emotionally dysregulated as a result of internal or external triggers of which the child and parent are unaware. When children become dysregulated they require the parent, teacher or therapist to help them become calm and bring their autonomic nervous system back to a state of homeostasis . This can be done verbally, by tone of voice, by warm, empathetic responses and by approaching the child in a way that is appropriate to their emotional and developmental age. Adoptive parents require education and training in order to be able to systematically carry out this way of parenting. However, in some situations this approach will not work and the child will become a danger to themselves and to others. In these situations, parents may have to physically contain their child. Family Futures parent preparation programme, which is a pre-cursor to our therapy programme, helps parents to carry this out in a way that is understanding of the genesis of the child's behaviour, the process by which feelings and emotions are neurologically mediated and regulated physiologically. Coupled with this is support and education for parents on strategies which help children to learn, not only the consequences of their actions, but how to manage their emotions themselves. We do not advocate parenting strategies which are punitive or harsh, but ones that are developmental age appropriate and help children to self-learn, self regulate and become independent.

If during a therapy session, a child becomes aggressive or violent, or upset and distressed, the therapist's role is to coach the parent to respond and behave appropriately. As we feel it is important that parents are helped to remain the primary attachment figure at all times and the adult who is in control of the child at all times. The therapists would never engage in restraint. They may however assist the parent to keep the child physically under control and safe. At times it may also be appropriate for the therapist to touch the child in a way that is reassuring or comforting. But again when children become distressed and upset we would invoke the parent to be the primary source of reassurance and comfort.

A Parent Protection Policy

The Parent Protection Policy should be read in conjunction with our Child Protection Policy, to which it is seen as complementary. This policy reflects one of Family Futures' underlying principles in our work with families, namely that the integrity and welfare of the family as a whole should be considered a priority. Just as children need safety and protection in a warm loving environment, adoptive parents and foster carers similarly have a right to their welfare and mental health being protected. Without parents who can function at an optimal level, children's experience of family life will be impoverished and their developmental needs will not be met. We are aware that this is a delicate balance to keep and though at all times the welfare of children is paramount, in our work we have to embrace the complexity of these two fundamental principles.

Children who have grown up in an abusive environment are prone to re-enact that abuse with significant others such as adoptive parents, foster parents or siblings. In our experience adoptive families who have had little support and/or are isolated from other adoptive families, often come to accept the unacceptable as the norm. Frequent attacks upon parents, particularly mothers, have become accepted as part of the family culture because parents are at a loss as to how to combat it without resorting to violence themselves. This we refer to as the 'battered mother syndrome' where verbal and physical assaults are normalised and where the 'victim' believes they are responsible in some way for the assault and are reluctant to report it.

At Family Futures we are aware of this phenomenon and we pro-actively raise the issue of verbal and physical assault with parents during our assessment and treatment programme. The staff at Family Futures work towards creating a trusting and accepting environment where parents can be open and honest and not feel blamed or judged. Accepting that there is a problem is the first step in finding a solution.

If parents are unable to exercise reasonable control over their child, then their ability to positively impact the child through nurture and engagement is diminished. A permissive approach, rather than to resolve or extinguish the behaviour tends to reinforce and perpetuate it. In our work with parents we therefore adopt the following approach:

Education support and advice on how to adopt a developmental re-parenting approach
To use proportionate and appropriate consequences for anti-social behaviour
In extreme situations, to reinforce the fact that the parent has a right to protect themselves and their family
That parents should report an incident of violent assault by the child on them or other members of the family to the Social Services responsible for the child or Social Services department for the area in which they live
If a situation involving violence, self-harm or running away is irresolvable by the parent then they should call the Police in the first instance, then the Social Services responsible for the child or Social Services department for the area in which they live
If such incidents occur frequently or the parent believes they might occur then we would suggest that they pro-actively in a non crisis situation contact their local Police e.g. Domestic Violence or Child Protection Unit requesting their support so that they will respond appropriately in an emergency. In some situations it is appropriate for the Police to do a home visit to caution the child regarding the seriousness and dangerousness of their actions.

In Summary

1.	Family Futures does not using Holding Therapy or other intrusive therapies.
2.	Parents need support and education in ways of safely managing impulsive and aggressive behaviour in children who have experienced early trauma.
3.	Parents need support in being empathetic and attuned to the needs of their children.
4.	In order for children to develop secure attachments, they need to have a structured environment in which they feel safe and protected.
5.	Parents need support and advice on how to manage aggressive acting out behaviour as we feel it's important that parents feel protected and safe.

These measures are designed to provide an effective, safe, structure so that parents can continue to live with their sometimes very challenging children.